Form 115a - Premium Tax Return Tax On Premiums Paid To Unauthorized Insurers
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1STATE OF CONNECTICUT
FORM 115A
DEPARTMENT OF REVENUE SERVICES
For Calendar Year
PO Box 2990
Hartford CT 06104-2990
PREMIUM TAX RETURN
TAX ON PREMIUMS PAID TO UNAUTHORIZED INSURERS
(Rev. 12/98)
Connecticut Tax Registration Number
Federal Employer Identification Number
Please change
Name and/or
Date Received (For Department Use Only)
Address if shown
incorrectly at right
SCHEDULE OF INSURANCE PURCHASED FROM UNAUTHORIZED INSURERS
Premium Allocated to
Code
Contract
Effective
Expiration
Name and Address of
Subject of
Description
Risks or Exposures Located (See Notes)
Number
Date
Date
Insurance Company
Insurance
of Coverage
within Connecticut
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Premium charged in Connecticut
Make checks payable to: COMMISSIONER OF REVENUE SERVICES
Total Column (7)
Tax Due: Multiply column 7 by 4% (.04)
Mail to:
Department of Revenue Services
PO Box 2990
Penalty _________ + Interest _________ = Total
Hartford CT 06104-2990
I declare under the penalties of false statement that I have examined this application and to the best of my knowledge and belief
it is true, complete and correct. Declaration of preparer (other than the taxpayer) is based on all information of which preparer has any knowledge.
Signature of Principal Officer
Title
Date
Telephone Number
(
)
Paid Preparer’s Signature
Date
Federal Employer Identification Number
Keep a copy
of this return
Firm Name and Address
for your
records
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