Form Lgt 140 - City, County, Or Urban County Government Insurance Premium Tax Annual Reconciliation

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Commonwealth of Kentucky, Office of Insurance
CITY, COUNTY, OR URBAN COUNTY GOVERNMENT INSURANCE PREMIUM TAX
ANNUAL RECONCILIATION
FILER INFORMATION
Complete either the information for a direct writer or surplus lines broker depending upon the filer type.
Insurance Company (Direct Writer):
Surplus Lines Broker:
Name
(Name)
(Title)
Address
(Address)
City, State, ZIP
(Phone)
Phone
(Email Address)
Email Address
Account Number ______________
Employer Identification Number
Tax Year Ending ______________
NAIC Number
LOUISVILLE METRO, KENTUCKY
Name of City, County, or Urban County Government:
SECTION I
Established
Premiums
Tax Payable
Collection Fee
Collected from
Additional Tax Due or
Tax Rate %
Collected
Retained
(Overpayment)
[(1) x (2)]
Policyholders
(1)
(2)
(4)
(6)
(3)
(5)
ST
1
QUARTER
Casualty
Fire & Allied Perils
Inland Marine
Life
Motor Vehicle
All Other Risks
Health (1)
Note
(1)
> Include only premiums received in the Metro Louisville Urban Service District (formerly the City of Louisville) on the Health Line.
Credits
(Form LGT 142)
Total
ND
2
QUARTER
Casualty
Fire & Allied Perils
Inland Marine
Life
Motor Vehicle
All Other Risks
Health (1)
Note
(1)
> Include only premiums received in the Metro Louisville Urban Service District (formerly the City of Louisville) on the Health Line.
Credits
(Form LGT 142)
Total
FORM LGT 140
MAILING ADDRESS: LOUISVILLE METRO REVENUE COMMISSION
P.O. BOX 37740  LOUISVILLE, KENTUCKY 40233-7740
Telephone: (502) 574-4860   Fax: (502) 574-4818   TDD: (502) 574-4811

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