Purchasing Group Annual Tax And Fees Report Form Page 2

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STATE OF DELAWARE DEPARTMENT OF INSURANCE

Original Report

PURCHASING GROUP

Amended Report

ANNUAL TAX AND FEES REPORT

PG ANNUAL

FOR THE CALENDAR YEAR 2011, DUE MARCH 1, 2012

PURCHASING GROUP (PG) INFORMATION AND TAX MAILING ADDRESS

Purchasing Group (PG)

List any other name by which the PG is doing

Name:

business in this or any other state:

Tax Address:

State of Domicile:

Contact Person:

Delaware PG ID#

Contact E-mail:

Federal EIN #:

Telephone #:

Ext.:

Fax #:

Date Registered in DE:

AGENT/SL BROKER INFORMATION

IMPORTANT: If the PG uses a surplus lines carrier, a licensed SL Broker must be listed.

Agent Name:

Agency Name:

Address:

DE Lic. #:

Do not write in this space

GENERAL INFORMATION

§§702 (a) (c) & 707(a): Premium Taxes and Fees

In accordance with 18 Del. C., §§ 702 (c) and 707(a), a premium tax of two percent (2%) is due for risks written and located in the State of Delaware.

Every authorized and f ormerly authorized insurer must show Gross Direct Premium Income*, including all policy membership and o ther fees and as sessments and all

other c onsideration rec eived for ins urance ( other th an as to Work er’s Compensation and Em ployer’s Liability, W et M arine and Tr ansportation ins urance, a nd A nnuity

contracts) covering property, subjects, or risks located, resident, or to be performed in Delaware, and including proper proportionate allocation of premiums under policies

covering persons, property, subjects, or risks located or resident, or to be performed in more than one state.

*Such income is to be determined by deducting from the total of all direct premium income (1) the am ount of retur ned premiums on canceled policies (but not including

the re turn of c ash s urrender v alues of li fe i nsurance policies), (2) th e unabsorbed p ortion of any de posit premium, an d (3) the amount retur ned t o p olicyholders a s

dividends and similar returns, whether paid in cash or credited or applied in reduction of premiums.

§ 8010(b): Purchasing group taxation

Premium taxes and taxes on premiums paid for coverage of risks resident or located in this State by a purchasing group or any members of the purchasing groups shall

be: (1) Imposed at the same rate and subject to the same interest, fines and penalties as that applicable to premium taxes and taxes on pr emiums paid for similar

coverage fro m a similar insurance s ource by other insureds; a nd (2) Paid f irst by s uch ins urance s ource, an d if not by s uch s ource by the age nt or br oker f or t he

purchasing group, and if not by such agent or broker then by the purchasing group, and if not by such purchasing group then by each of its members.

PART 1

PREMIUM TAX AND FEES SUMMARY REPORT

Refer to Instructions on Page 2

(1) INSURANCE SOURCE (Company Name)

NAIC #

PREMIUM AMOUNT

(2) TAX AMOUNT

0.00

Tax Amount Due From PG

All questions should be directed to:

( 3 )