Premium Tax Report Industrial Insured - New Hampshire Insurance Department
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1PREMIUM TAX REPORT
New Hampshire Revised Statutes Annotated (RSA) 406-B:16, VI
Industrial Insured
This report is to be filed with the New Hampshire Insurance Department, 21 South Fruit Street, Suite 14, Concord, New Hampshire
03301. Every Industrial Insured shall pay to the Commissioner of Insurance before March 1 next succeeding the calendar year in which
the insurance was so effectuated, continued, or renewed a premium tax of three per cent of the gross premiums. Payment should
accompany this form with checks 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
3% 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 @ 3%
- 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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