Premium Tax Report Independently Procured Unauthorized Insurance - New Hampshire Insurance Department

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PREMIUM TAX REPORT - Section 406-B: 17, New Hampshire Statutes
Independently Procured Unauthorized Insurance
Year ending December 31, _______
This report is to be filed with the New Hampshire Insurance Department, 21 South Fruit Street, Suite 14, Concord, New
Hampshire 03301, within sixty days after the date on which such insurance is procured. Checks should be made payable to:
NH Insurance Dept.
__________________________________
________________________________________________
___________________
Person or Organization Insured
Address (including Zip Code)
Date
__________________________________
Name of Insurance Manager
Contract
Effective
Expiration
Name and Address of
Description of
Premium
4% Tax on
Number
Date
Date
Insurance Company
Type of Coverage
Charged
Premium
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Premium Charged - Total Col. (6) $_____________________
Tax Due @ 4%
- Total Col. (7) $_____________________
Amount Enclosed
$_____________________
The undersigned insured hereby acknowledges that the above listed insurance is not eligible for protection under the New Hampshire
Insurance Guaranty Association.
The undersigned certifies that this report is true and correct according to the best of his information, knowledge, and belief.
______________________________________________________________
____________________________________________
Insured
Date

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