Form Pf-Y - Annual Premium Tax Statement For A Foreign Insurance Company - Alabama Department Of Insurance

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STATE OF ALABAMA
PF-Y
DEPARTMENT OF INSURANCE
ANNUAL PREMIUM TAX STATEMENT - FOREIGN INSURANCE COMPANY-CASUALTY BUSINESS
For the Year Ending December 31, _____________
INSTRUCTIONS
PENALTIES: Any Company failing to file its Premium Tax Return (even when no tax is due) or failing to pay such taxes on a timely
basis shall be subject to a penalty of $1,000 to $10,000, to be assessed by the Commissioner.
RETURNS MUST BE RECEIVED BY THE DUE DATE TO BE ACCEPTED AS TIMELY FILED.
Please refer to the NAIC Checklist at
for further instructions. (Notes D, Q & R)
( ) The Alabama Office Facilities Credit Worksheet must accompany this Return if paying at a rate less than the 3.6% maximum.
( ) The Coastal Incentive Credit Worksheet must accompany this Return if this credit is taken.
( ) Make checks payable to: Alabama Department of Insurance.
( ) Submit THREE CHECKS: one in payment of Renewal Fees, one in payment of Premium Taxes, and one in payment of Retaliatory Tax.
( ) Please mail the Annual Premium Tax Return, Retaliatory Tax Statement and checks to:
POSTAL SERVICE
COURIER OR EXPRESS SERVICE
Alabama Department of Insurance
Alabama Department of Insurance
c/o Compass Bank
c/o Compass Bank
nd
P. O. Box 830691
701 South 32
Street
Birmingham, AL 35283-0691
Birmingham, AL 35233
NAIC#:
_______________________________________________________________________
Name of Company
______________________________________
________________________________________________________________
Preparer’s Signature
Name and Title (Print)
Telephone No _______________________________
E-Mail Address____________________________________________
PREMIUM TAXES AND FEES
(Pay License Renewal Fees on Casualty Return PF-Y only):
$ ____________________
FEES: Renewal of Certificate of Authority
PI
PI:
($505, $1,005 or $1,505-Please see instructions)
25.00
$ ________
______
Annual Statement Filing Fee:
PJ
Check No._________________
State of _______________________________________. County of _______________________________________________________
_______________________________________________, President and _________________________________________Secretary
of the __________________________________________________________________________________________Insurance Company
being duly sworn, each for himself, deposes and says, that they are the above described officers of said Company and that the foregoing statement of
business transacted during such year and showing the true status of same on December 31, of such year, is full and correct according to the best of
their information, knowledge and belief, respectively.
Subscribed & sworn before me this ___________________________
______________________________________ President
Day of _____________________, 20 ___________.
_______________________________________ Secretary
Notary Public
My commission expires _____________________________________
___________________________________
-- OVER --
Revised 10/6/2014

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