Form 115nin - Nonadmitted Insurance Premium Tax Return

Department of Revenue Services

Form 115NIN

For calendar quarter ending:

State of Connecticut

2 0



___ ___

___ ___ ___ ___

PO Box 2990

Nonadmitted Insurance Premium Tax Return

M M

Hartford CT 06104-2990

Complete this return in blue or black ink only.

(New 01/14)

Taxpayer name

Connecticut Tax Registration Number



Taxpayer

Address

Number and street

PO box

Federal Employer ID Number (FEIN)

Type



City, town, or post ofﬁ ce

State

ZIP code

Date received (DRS use only)

print.





Address change

Amended return

Schedule of Insurance Purchased From Unauthorized Insurers

Attach additional schedules as necessary. Continue item numbering sequence.



Contract number

Effective date

Expiration date

Gross premiums

(whether or not the risks

Insurer name

or exposures are within

Connecticut)

Address

City

State

ZIP code

Subject of insurance

Description of insurance



Contract number

Effective date

Expiration date

Gross premiums

(whether or not the risks

Insurer name

or exposures are within

Connecticut)

Address

City

State

ZIP code

Subject of insurance

Description of insurance



Contract number

Effective date

Expiration date

Gross premiums

Insurer name

(whether or not the risks

or exposures are within

Connecticut)

Address

City

State

ZIP code

Subject of insurance

Description of insurance



Contract number

Effective date

Expiration date

Gross premiums

Insurer name

(whether or not the risks

or exposures are within

Address

City

State

ZIP code

Connecticut)

Subject of insurance

Description of insurance

Make check payable to

1. Enter total gross premiums.





Commissioner of Revenue Services

2. Tax: Multiply Line 1 by 4% (.04).





Mail to:

Department of Revenue Services

3. Penalty



_____________ + Interest



State of Connecticut

_______________

PO Box 2990

4. Amount due: Add Line 2 and Line 3.



  

Hartford CT 06104-2990

Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) and, to the best of my knowledge and belief, it is

true, complete, and correct. I understand the penalty for willfully delivering a false return or document to the Department of Revenue Services (DRS) is a ﬁ ne of not more than $5,000,

imprisonment for not more than ﬁ ve years, or both. The declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge.

Signature of principal ofﬁ cer

Date

Daytime telephone number

Sign

(

)

Here

Print name of principal ofﬁ cer

Title

Keep a copy

for your

records.