Form 74a117 - Monthly Insurance Surcharge Report Domestic Mutual, Cooperative And Assessment Fire Insurer

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74A117 (11-98)

MONTHLY INSURANCE SURCHARGE REPORT

FOR OFFICIAL USE ONLY—STA. 62

Commonwealth of Kentucky

DOMESTIC MUTUAL, COOPERATIVE

__ / __ __ / __ __

REVENUE CABINET

AND ASSESSMENT FIRE INSURER

Tax

Mo.

Yr.

(Excluding any company that transfers its corporate domicile

Account Number __ __ __ __ __

to Kentucky after July 15, 1994.)

See reverse for information or call the Miscella-

Check Here if Annual Filer

Check Here if Amended Return

neous Tax Section, (502) 564-4409.

Name and Address

Report for Month of

Mo.

NAIC

–

FEIN

1. Total premiums, assessments and other charges collected on risk

located in Kentucky (exclude municipal taxes) ................................................................... $

2. Less amounts not subject to surcharge:

A. Premiums returned to policyholders on terminated

policies ....................................................................... $

B. Premiums collected for:

Accident and health insurance ................................... $

Federal insured crop insurance .................................. $

Federal insured flood insurance ................................. $

Reinsurance ................................................................ $

Title insurance ............................................................ $

Workers' compensation .............................................. $

C. Premiums collected from:

Federal govenment ..................................................... $

Resident nonprofit educational and charitable

institutions (501(c)(3) status) ..................................... $

Resident nonprofit religious institutions for real,

tangible and intangible property coverage only ........ $

State and local government for real property

coverage only ............................................................. $

D. Total amount not subject to surcharge .......................................................................... $

3. Amount subject to surcharge (line 1 minus line 2D) ........................................................... $

4. Surcharge due (line 3 times .015) ......................................................................................... $

5. Penalty (see reverse) ............................................................................................................. $

6. Interest (see reverse) ............................................................................................................. $

7. Amount due (add lines 4, 5 and 6) ........................................................................................ $

8. Adjustments (attach supporting documentation) .................................................................. $

9. Total amount due (line 7 plus or minus line 8) .................................................................. $

Make check payable to Kentucky State Treasurer and mail return with payment to:

Kentucky Revenue Cabinet

Mailing Address:

P.O. Box 1303, Frankfort, KY 40602-1303

Overnight Address: 1266 Louisville Road, Frankfort, KY 40601

I, the undersigned, a principal officer of the above-named company, certify that I have examined this report and it is, to the best of my knowledge and

belief, a true, correct and complete report.

Principal Officer's Information

Preparer's Information

Signature

Print Name

Title

Telephone Number

Date