Form Oci 27-015 - Supplies Lines Tax Report Form - Wisconsin

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surplus lines
State of Wisconsin
tax report
Office of the Commissioner of Insurance
P. O. Box 7873
Ref: Section Ins 6.17,
Madison, WI 53707-7873
Wis. Adm. Code
To: Surplus Lines Agent
Please find attached the Surplus Lines Tax Report required pursuant to s. Ins 6.17, Wis. Adm.
Code.
please indicate the individual surplus lines agent that the business was
written through, do not indicate an agencY naMe when subMitting this
Filing.
The agent will be held accountable for the tax filings; failure to file may result in disciplinary
action. iF there has been no business written during the prior Year,
please return the tax ForM to this oFFice indicating “no business
written.”
Return this form along with check payable to the Commissioner of Insurance on or before
March 1.
If you have any questions, please contact:
Yvonne Sherry
(608) 266-0091
yvonne.sherry@wisconsin.gov
or
Julie Wipperfurth
(608) 261-8284
julie.wipperfurth@wisconsin.gov.
Attachment
OCI 27-015A (R 10/2012)

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