Form 308 - New Mexico Public Regulation Commission
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1NEW MEXICO PUBLIC REGULATION COMMISSION
Financial Audit Bureau
COMMISSIONERS
P.O. Box 1269
1120 Paseo de Peralta
DISTRICT 1 JASON MARKS
Santa Fe, NM 87504-1269
DISTRICT 2 PATRICK H. LYONS, CHAIRMAN
505-827-5781
DISTRICT 3 JEROME D. BLOCK, VICE CHAIRMAN
DISTRICT 4 THERESA BECENTI-AGUILAR
DISTRICT 5 BEN L. HALL
Superintendent of Insurance
John G. Franchini
Insured’s Name and Address:
SS#/Tax Id #: _______________________
______________________________________
Telephone #: _______________________
______________________________________
______________________________________
Pursuant to Section 59A-15-4 NMSA 1978 EACH INSURED IN THIS STATE THAT PROCURES, CONTINUES OR
RENEWS INSURANCE WITH A NON-ADMITTED INSURER ON A RISK LOCATED OR TO BE PERFORMED IN
WHOLE OR IN PART IN THIS STATE, OTHER THAN INSURANCE PROCURED THROUGH SURPLUS LINES SHALL,
WITHIN NINETY (90) DAYS AFTER THE DATE SUCH INSURANCE WAS SO PROCURED, CONTINUED OR
RENEWED, FILE WRITTEN REPORT WITH THE SUPERINTENDENT AND PAY THE APPLICABLE PREMIUM TAX.
PLEASE COMPLETE THE NECESSARY INFORMATION AND ENCLOSE PAYMENT
FOR THE INDICATED TAX:
Term of Coverage: From: __________________ To: _________________ Policy #: ________________
Description of Coverage:
_____________________________________________________________________________________________
_______________________________________________________________________________________________________________
___________________________________________________________________________
Company/Insurer: ________________________
Agent: _____________________________________
Address: _______________________________
Address: ____________________________________
_______________________________________
____________________________________
Amount of premium charged:
$____________________
Premium tax due amount (3.003% of previous line):
$____________________
DO NOT WRITE ON THESE LINES
ACCOUNT #54 $____________________ ACCOUNT #78
$____________________
PLEASE COMPLETE THE FOLLOWING:
____________________________ ___________
Print or type preparers name
Date
PLEASE RECORD
_________________________________________
.
Preparer’s Signature & Title
Check Number: ______________
FORM 308
Amount Remitted: ____________
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