Form 08-1240 - Unauthorized Insurer'S Tax Form - Alaska Division Of Insurance Page 2
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2Alaska Division of Insurance
P.O. Box 110805
Juneau, AK 99811-0805
Unauthorized Insurance and Wet Marine & Transportation Tax Report
(To be postmarked on or before March 1)
Part 1:
1. Gross Premium: Unauthorized Insurance:
___________ X 3.7% $____________
2. Gross Premium: Wet Marine and Transportation Insurance: ___________ X .75% $____________
3. Total Tax Due (lines 1 + 2).................................................................................
$____________
4. Late Payment fee (only if assessed by the division)
($1,000 or 10% of tax due, whichever is greater) .................................................. $____________
Interest (1% per month of tax due) ........................................................................ $____________
Late Payment Penalty ($100 per day of 25% of tax due, which is greater)............ $____________
Part 2:
Name of Insurance Company
For the Calendar Year of:
Mailing Address
City, State, and ZIP Code
Organized Under the Laws of:
Contact Name
Phone Number
E-mail
I, ______________________________________, certify that I am the____________________ of the
above-named insurance company; and that the Unauthorized Insurance and Wet Marine &
Transportation Tax Report of premium and taxes is a complete, true and correct statement of all
premiums and taxes on all business written as shown on the attached annual statement exhibit where
Alaska is the home state of the insured for the year ending December 31, _____.
___________________________________
(President – Secretary)
Part 3:
Name of Broker/Producer
AK License No.
For the Calendar Year of:
Mailing Address
City, State, and ZIP Code
Contact Name
Phone Number
E-mail
I, ______________________________________, certify that I am a producer/broker of the above-
named Alaska license, and that the Unauthorized Insurance and Wet Marine & Transportation Tax
Report of premiums and taxes is a complete, true and correct statement of all wet marine &
transportation insurance or unauthorized insurance written as shown on the attached list for insurance
where Alaska is the home state of the insured for the year ended December 31,_____.
___________________________________
(Producer/Broker)
Form 08-1240 (rev 8/14)
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