Unauthorized Insurer Business Written & Premium Tax Report Surplus Lines Insurer Risk Retention Group - South Dakota Division Of Insurance Page 2
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1
2PART III.
PREMIUM TAX CALCULATION: (
Only Risk Retention Groups paying the premium tax must complete
this section.)
Multiply Line (1) x SD Fire Premium Tax Rate: 3% =
(4)
$_________________
Line (2) x SD All Other Premium Tax Rate: 2.5% = (5)
$_________________
_________________
Add (4) + (5) :
Total Premium Tax =
(6)
$________________
Deduct: Credits Due (Attach Itemized List or Explanation):
(7)
$________________
*** Quarterly payments (If any).
Date
Date
Check
Amount
Quarter
Due
Paid
Number
Paid
First
4/30
______
_______
$___________
Second
7/31
______
_______
$___________
Third
10/31
______
_______
$___________
Fourth
1/31
______
_______
$___________
Sub-Total of Quarterly Payments:
(8)
$________________
Total: (Line 6 minus Line 7 minus Line 8)
(9)
$________________
Add: **** Interest, Fines, Penalties Due (If Any.):
(10)
$________________
Total Amount Due: (Line 9 plus Line 10)
(11)
$_________________
================
*** An insurer or its representative remitting in excess of five thousand dollars ($5,000.00) premium tax in the previous
year must pay premium taxes on a quarterly basis the following year. [SDCL 58-32-44].
**** All taxes and installments paid after the Date Due must include a penalty fee of one and one-half percent (1.5%) per
month, or fraction thereof, on the unpaid balance. [SDCL 10-44-16].
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
State of _________________________)
)
County of _____________________ __)
I, _______________________, being first duly sworn, say and depose on oath, that I am the
(Name)
___________________________of _______________________________, that I am familiar
(Official Title)
(Company Name)
with the subject matter reported in the foregoing document, and that the amounts set forth therein are correct
to the best of my information, knowledge and belief.
______________________________________
(Signature)
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