Utah Premium Memorandum printable pdf download

Utah Premium Memorandum

UTAH PREMIUM MEMORANDUM

(Submit one copy of

Surplus Line Association of Utah

(Submit two copies of

endorsement)

this form)

6711 South 1300 East

Salt Lake City, Utah

84121

944-0114

(801)

For additional premiums, return premiums, installment premiums, or cancellations

Check appropriate box:

Additional

Return

Installment

Cancellation

Premium

Policy Number: _______________________________

Premium

$_______________

Name of Insured: _______________________________

.0425 Premium Tax

$_______________

Name of “Recognized” Surplus Line Company

.0015 Stamping Fee $_______________

Total

$_______________

______________________________________________

(

Must be on the “recognized” list.)

Effective date of this

premium adjustment____________________________

___________________________

Surplus Line Producer

___________________________

Agency Name

Remarks:

__________________________________________________________________________________________

Utah Premium Memorandum