Form Up-1 Ins - Insurance Company Holder Report Form - 2009
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1UP-1 Ins (Rev. 01/10)
INSURANCE COMPANY
HOLDER REPORT FORM
2009
This form must accompany all holder reports
ARE YOU A 1ST TIME FILER? Y [ ] N [ ]
DID YOU ATTACH A CD? Y [ ] N [ ]
ELECTRONIC FILERS: Submit a UP-1Ins for each business included on the CD. ZERO BALANCE REPORTS REQUIRED
HOLDER INFORMATION
1. FEDERAL EMPLOYER ID#
2. HOLDER (Business Name)
ADDRESS
CITY, STATE, ZIP CODE
3. IS THIS REPORT BEING PREPARED BY AN AGENT ON BEHALF OF THE HOLDER?
Y [
]
N [
]
IF YES, FURNISH AGENT NAME
AND ADDRESS:
4. NAME OF CONTACT PERSON
5. TELEPHONE
6. E-MAIL ADDRESS
(
)
7. DATE OF INCORPORATION
9. PRIMARY BUSINESS ACTIVITY
8. STATE OF INCORPORATION
10. NO. OF EMPLOYESS
11. ANNUAL SALES/PREMIUMS
12. PREMIUMS WRITTEN IN GA
13. TOTAL ASSETS
REPORT INFORMATION
INTANGIBLE PROPERTY - (Outstanding Checks)
14a. Total accounts $50.00 or more _______________________ 14b. Dollar Value $ __________________________
14c. Total accounts less than $50.00 _______________________ 14d. Dollar Value $ __________________________
14e. Report Total $ __________________________
OTHER PROPERTY (Securities)
14f. Number of shares of stock __________________
VERIFICATION STATEMENT
I,
certify that I have caused to be prepared and have examined this report
totaling $
as to property presumed abandoned under the “Disposition of Unclaimed Property Act”
for the year ended as stated, that I am duly authorized to execute this verification by the holder and that I believe said report
to be true, correct and complete.
Signature of Responsible Officer
Printed or Typed Name Responsible Officer
Title of Responsible Officer/Agent
Date
FOR OFFICE USE ONLY
CD
CHECK NUMBER
CHECK DATE
CHECK AMOUNT
DATE DEPOSITED
BATCH NO.
RECEIPT NO.
REPORT ID
HOLDER NO.
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