Form Lgt 141 - City, County, Or Urban County Government Quarterly Insurance Premium Tax Return

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Commonwealth of Kentucky, Office of Insurance
CITY, COUNTY, OR URBAN COUNTY GOVERNMENT QUARTERLY INSURANCE PREMIUM TAX RETURN
FILER INFORMATION
Complete either the information for a direct writer or surplus lines broker depending upon the filer type.
Insurance Company (Direct Writer):
Surplus Lines Broker:
Name
Name
Address
Address
City, State, ZIP
Phone
City, State, ZIP
Email Address
Phone
Account Number ______________
Email Address
Employer Identification Number
For the Quarter Ending ______________
NAIC Number
LOUISVILLE METRO, KENTUCKY
Name of City, County, or Urban County Government:
IF NO PREMIUMS WERE RECEIVED, WRITE “NONE” ON FORM, SIGN, AND RETURN.
(1)
(2)
(3)
(4)
(5)
Established
Premiums
Tax Payable
Collection
Amount Collected
Line of Insurance
Tax Rate (%)
Collected
(Column 1 x Column 2)
Fee Retained
from Policyholders
Casualty:
_________
________________
______________
______________
______________
Fire & Allied Perils:
_________
________________
______________
______________
______________
Inland Marine:
_________
________________
______________
______________
______________
Life:
_________
________________
______________
______________
______________
Motor Vehicle:
_________
________________
______________
______________
______________
Other:
________________________
_________
________________
______________
______________
______________
________________________
_________
________________
______________
______________
______________
Health (1):
_________
________________
______________
______________
______________
(1) Note > Include only premiums received in the Metro Louisville Urban Service District (formerly the City of Louisville) on the Health Line
of Insurance.
Credits: (Form LGT 142)
________________
______________
______________
______________
Total:
________________
______________
______________
______________
I hereby certify that the information provided is an accurate statement of the premiums collected.
__________________________________________________________________________
Date: ______________
Signature of Person Responsible for Preparing This Return/Title
FORM LGT 141
MAILING ADDRESS: LOUISVILLE METRO REVENUE COMMISSION
P.O. BOX 37740 • LOUISVILLE, KENTUCKY 40233-7740
Telephone: (502) 574-4860 • • Fax: (502) 574-4818 • • TDD: (502) 574-4811

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