Independently Procured Coverage Form - Nevada Department Of Taxation
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1
2STATE OF NEVADA
DEPARTMENT OF TAXATION
RENO OFFICE
4600 Kietzke Lane
Web Site:
Building L, Suite 235
Reno, Nevada 89502
1550 College Parkway, Suite 115
Phone: (775) 687-9999
Carson City, Nevada 89706-7937
Fax: (775) 688-1303
Phone: (775) 684-2000
Fax: (775) 684-2020
BRIAN SANDOVAL
LAS VEGAS OFFICE
HENDERSON OFFICE
Governor
Grant Sawyer Office Building, Suite1300
2550 Paseo Verde Parkway, Suite 180
ROBERT R. BARENGO
555 E. Washington Avenue
Henderson, Nevada 89074
Chair, Nevada Tax Commission
Las Vegas, Nevada 89101
Phone: (702) 486-2300
Phone: (702) 486-2300
Fax: (702) 486-2373
Fax: (702) 486-3377
Executive Director
INDEPENDENTLY PROCURED COVERAGE
Pursuant to NRS 680B.040, a report of coverage purchased from an unauthorized, foreign or
alien insurer must be filed within 30 days after the date the policy was procured, continued or
renewed.
Submit one form per policy, continued coverage or renewal
1.
Name and Address of insured(s):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
2.
Name and address of insurer:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
3. Subject and location of the risk insured (attach additional sheets if necessary):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
4.
Does this insurance also cover a subject of insurance resident, located or to be performed
outside Nevada? _______Yes _______No.
If “yes”, attach method and documentation
supporting the allocation of premium to the Nevada portion of the risk.
5.
General description of the coverage or attach a copy of the declaration page:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
6.
Policy Number: ____________________. Effective dates of coverage: ______________.
Is this a renewal? ______Yes ______No. If “yes”, previous policy number _____________.
If “no”, previous insurer and policy number: _______________________________________
___________________________________________________________________________
IIC Page 1
Revised 1/8/07
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