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Form 1076 - Annual Municipal Premium & Tax Report - Louisiana Department Of Insurance - 2011

Louisiana Department of Insurance

Form 1076

2011

Tax Division

P. O. Box 94214

Annual Municipal

Baton Rouge, LA 70804-9214

Premium & Tax Report

Phone (225) 342-5825

Fax (225) 342-9708

Due March 1, 2012

Company Name

Mailing Address

Contact Person

Telephone Number

E-Mail Address

Fax Number

Federal ID #

NAIC NUMBER

State of Domicile

NOTICE – Premiums reported on this form must be equal to premiums reported on Form 1061, Item A1 + Item B1. All premiums must be allocated to a

municipality or parish as listed in this report, without exception. If a municipality is not on this list, the premium must be allocated to the Parish where the

municipality is located. DO NOT add or change the municipalities or parishes appearing on this list. All premiums for municipalities located within Orleans

Parish (not listed below) must be allocated to the City of New Orleans (Code 1320). SEE INSTRUCTIONS ON PAGE 4.

MUNICIPAL TAX

CODE

MUNICIPALITY OR PARISH

DIRECT PREMIUMS

LIABILITY

CODE

MUNICIPALITY OR PARISH

DIRECT PREMIUMS

LIABILITY

Abbeville

195

Bonita

Abita Springs

200

Bossier City

Acadia Parish

205

Bossier Parish

Addis

210

Boyce

Albany

220

Breaux Bridge

Alexandria

221

Broussard

Allen Parish

230

Brusly

Amite

240

Bunkie

Anacoco

250

Caddo Parish

Angie

260

Calcasieu Parish

Arcadia

262

Caldwell Parish

Arnaudville

263

Calvin

Atlanta

266

Cameron Parish

Ascension Parish

270

Campti

Ashland

271

Cankton

Assumption Parish

272

Carencro

Athens

274

Castor

Avoyelles Parish

275

Catahoula Parish

100

Baker

276

Central

110

Baldwin

277

Chataignier

115

Ball

280

Chatham

120

Basile

281

Cheneyville

125

Baskin

284

Choudrant

130

Bastrop

290

Church Point

140

Baton Rouge

300

Claiborne Parish

141

Beauregard Parish

305

Clarence

145

Belcher

307

Clarks

150

Benton

310

Clinton

160

Bernice

320

Colfax

170

Berwick

330

Columbia

172

Bienville Parish

340

Collinston

176

Bienville

343

Concordia Parish

180

Blanchard

345

Converse

190

Bogalusa

350

Cottonport

Form 1076 (Revised 01/12)

THIS DOCUMENT IS EXEMPT FROM PUBLIC RECORDS LAW UNDER R.S. 44§4

Page 1 of 6

Form 1076 - Annual Municipal Premium & Tax Report - Louisiana Department Of Insurance - 2011

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