Form 800 - Virginia Insurance Premiums License Tax Return - 2014 Page 2
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1
2Form 800
2014 Virginia Insurance Premiums
*VAF800214888*
Page 2
License Tax Return
Company Name
Federal Employer ID Number
Schedule of Merger/Acquisition
List the name/address, FEIN and NAIC/License Number of any company included in this return as a result of a merger/acquisition.
Submit copies of this schedule if additional space is needed.
Company Name/Address
FEIN
NAIC/License #
.
Under penalty of perjury, I declare that I have examined this report and to the best of my knowledge and belief, it is true, correct and complete
Signature of Officer
Title
Date
Printed Name
Preparer’s Name
Preparer’s Phone Number
Preparer’s FEIN/PTIN/SSN
Vendor Code
By checking this box, I authorize the Department to discuss this return with the preparer listed above.
VA TAX
6201172
Rev 05/14
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