California Form 570 Draft - Nonadmitted Insurance Tax Return - 2012 Page 3

Policyholder Name: ________________________________________________________ Policyholder’s ID No.: _ _______________________

Part III Insurance Contracts – If you have more than 24 policies to report, enter the additional policies on another Side 2 of Form 570. Total each Side 2

on the bottom separately. Do not create a schedule to report additional policies. We only accept and process official versions of Side 2 of Form 570.

PRINT CLEARLY

Policy Number

Name of each Nonadmitted Insurance Company

Type of Insurance Coverage

Location of Risks

Total Premium

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Side 2 Form 570

2011

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