Form 74a110 - Kentucky Estimated Insurance Premiums Tax - 2008
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2
374A110 (11-07)
FOR OFFICIAL USE ONLY
KENTUCKY ESTIMATED
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
INSURANCE PREMIUMS TAX
3
2
0 6 0 8
*
___ ___ / ___ ___ ___ ___ / ___
Tax
Year
Tr.
For Calendar Year 2008
Account Number ___ ___ ___ ___ ___
Due June 1, 2008
NAIC/
FEIN __ __ – __ __ __ __ __ __ __
TAX ID
FIRST INSTALLMENT
Check appropriate block:
Name of Company
Report based on previous year’s liability
Address
Number and Street
Report based on current year estimate
City, Town or Post Office
State
ZIP Code
.
A. Premiums tax on life and health policies ..................................................
(01)
$
B. Premiums tax on other than life policies (excluding
.
workers’ compensation policies) ...............................................................
(02)
.
C. Retaliatory taxes and fees on foreign and alien insurers ..........................
(06)
.
D. Total installment due (total of lines A, B and C) ......................................
$
I, the undersigned, declare under the penalties of perjury, that I have examined these returns, including all accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct and complete.
___________________
_________________________________________
_____________________
Date
Signature of Officer or Agent
Title of Officer
_________________________________________
_____________________
Print or Type Name of Officer or Agent
Telephone Number
DETACH BEFORE MAILING
74A110 (11-07)
FOR OFFICIAL USE ONLY
KENTUCKY ESTIMATED
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
INSURANCE PREMIUMS TAX
3
2
1 0 0 8
*
___ ___ / ___ ___ ___ ___ / ___
Tax
Year
Tr.
For Calendar Year 2008
Account Number ___ ___ ___ ___ ___
Due October 1, 2008
NAIC/
FEIN __ __ – __ __ __ __ __ __ __
TAX ID
SECOND INSTALLMENT
Check appropriate block:
Name of Company
Report based on previous year’s liability
Address
Number and Street
Report based on current year estimate
City, Town or Post Office
State
ZIP Code
.
A. Premiums tax on life and health policies ..................................................
(01)
$
B. Premiums tax on other than life policies (excluding
.
workers’ compensation policies) ...............................................................
(02)
.
C. Retaliatory taxes and fees on foreign and alien insurers ..........................
(06)
.
D. Total installment due (total of lines A, B and C) ......................................
$
I, the undersigned, declare under the penalties of perjury, that I have examined these returns, including all accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct and complete.
___________________
_________________________________________
_____________________
Date
Signature of Officer or Agent
Title of Officer
_________________________________________
_____________________
Print or Type Name of Officer or Agent
Telephone Number
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