Independently Procured Coverage Form - Nevada Department Of Taxation Page 2

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7.
Current Premium: Insurer’s Charge
____________________________________
Policy Fee
____________________________________
Other Fees
____________________________________
Commission
____________________________________
Dividends or Credits
____________________________________
8.
Name, address, telephone number of person responsible for the placement of this policy:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
9.
Exact location where this insurance was purchased and negotiated:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
10. Name and address of broker or individual who assisted in the purchase of this insurance:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
11. Amount of premium tax submitted with this form: $______________________________
Contact the Department of Taxation if you are uncertain of the tax rate or how to calculate the
premium.
I ________________________________, in my capacity as __________________________
for ___________________________________, certify the foregoing is a full, true and correct
statement of facts.
_______________________________________________
________________________
Signature
Date
_______________________________________________
Print or Type Name & Title
_______________________________________________
Telephone Number
State of Nevada
County of __________________
Signed or attested to before me on the ________ day of ________________, 20 _______, by
_________________________________________.
(NAME OF PERSON SIGNING DOCUMENT)
NOTARY STAMP
______________________________________________________________
(NOTARY PUBLIC)
IIC Page 2
Revised 1/8/07

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