Form 74a110 - Kentucky Estimated Insurance Premiums Tax - 2010
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2
374A110 (12-09)
FOR OFFICIAL USE ONLY
KENTUCKY ESTIMATED
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
INSURANCE PREMIUMS TAX
3
2
0 6 1 0
*
___ ___ / ___ ___ ___ ___ / ___
Tax
Year
Tr.
For Calendar Year 2010
Account Number ___ ___ ___ ___ ___
Due June 1, 2010
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 Offi ce
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 Offi cer or Agent
Title of Offi cer
___________________________________________
______________________
Print or Type Name of Offi cer or Agent
Telephone Number
DETACH BEFORE MAILING
74A110 (12-09)
FOR OFFICIAL USE ONLY
KENTUCKY ESTIMATED
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
INSURANCE PREMIUMS TAX
3
2
1 0 1 0
*
___ ___ / ___ ___ ___ ___ / ___
Tax
Year
Tr.
For Calendar Year 2010
Account Number ___ ___ ___ ___ ___
Due October 1, 2010
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 Offi ce
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 Offi cer or Agent
Title of Offi cer
___________________________________________
______________________
Print or Type Name of Offi cer or Agent
Telephone Number
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