Unauthorized Insurer Business Written & Premium Tax Report Surplus Lines Insurer Risk Retention Group - South Dakota Division Of Insurance

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SOUTH DAKOTA DIVISION OF INSURANCE
445 EAST CAPITOL AVENUE, 1ST FLOOR
PIERRE, SD 57501
(605) 773-3563
UNAUTHORIZED INSURER BUSINESS WRITTEN & PREMIUM TAX REPORT
SURPLUS LINES INSURER -- RISK RETENTION GROUP
Date Due: April 1
st
nd
rd
th
1
QTR _______due April 30 / 2
QTR_______due July 31 / 3
QTR_______due Oct 31 / 4
QTR________due Jan 31, __________. (Please check which report is being filed – Qtrly/Annual )
(ENTER YEAR)
NAME:
________________________________________
NAIC NO. __________
ADDRESS:_____________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
CONTACT PERSON:______________________________ PHONE:____________________
(PLEASE PRINT)
.
PART I. DIRECT WRITTEN PREMIUM PRODUCER REPORT
(
All insurers complete this section)
List the name & address of all South Dakota Licensed Surplus Line Brokers responsible for placing the
direct business written on South Dakota resident risks, the name and address of the insured, date effective,
policy number and amount of the premium. If not applicable, list business or individual self-procuring.
.
Attach additional pages if necessary
PROD. TOTAL AMOUNT
NAME
ADDRESS
CLASS*
WRITTEN
1.
2.
3.
______________
TOTAL PREMIUMS WRITTEN
$
**
=============
* Producer Classes: (1) South Dakota Surplus Lines Broker
(2) Individual Self-Procured
**This figure must match Part II, Line 3.
PART II. DIRECT PREMIUM WRITTEN REPORT.
(All insurers complete this section.)
1. Direct Premium Written 1/1/_____ to 12/31/_____:
Fire Premium:
.
.
.
.
.
.
.
.
(1)
$___________________
All Other:
.
.
.
.
.
.
.
.
(2)
$___________________
___________________
Add: (1) + (2)
Total Direct Written Premium
(3)^ $___________________
===============
^ Cross-check: A.S. - SD State Page & Schedule T.

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