Form 115ar - Report Of Procurement, Continuance Or Renewal Of Insurance With Unauthorized Insurer

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STATE OF CONNECTICUT
DEPARTMENT OF REVENUE SERVICES
Excise/Public Services Subdivision
PO Box 2990 Hartford CT 06104-2990
REPORT OF PROCUREMENT, CONTINUANCE OR RENEWAL
OF INSURANCE WITH UNAUTHORIZED INSURER
1.
Name and Address of the Insured __________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
2.
Contract Number _______________________________
Premium Charged $ ____________________________________
3.
Effective Date __________________________________
Expiration Date ________________________________________
4.
Name and Address of the Insurer __________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
5.
General Description of Coverage ___________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
6.
Subject of the Insurance _________________________________________________________________________________
_____________________________________________________________________________________________________
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
Pursuant to Conn. Gen. Stat. §38a-277, this report must be filed with the Commissioner of Revenue Services within 60 days after
the date insurance is procured, continued or renewed with any unauthorized insurer. A separate report is required for each new or renewal
insurance contract. Form 115A, Premium Tax Return, must be filed, and a 4% tax (on the premium charged for such insurance during the
calendar year) must be paid to the Commissioner of Revenue Services on or before March 1 of the next succeeding calendar year.
FORM-115AR (12/98)

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