Form Dem - Domestic Companies Other Than Life - 2013
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4DEM-(11-13)
STATE OF NEW JERSEY
2013
DOMESTIC COMPANIES OTHER THAN LIFE
Insurer NAIC Code Number
Type or print the requested information
FEDERAL EMPLOYER I.D. NUMBER
COMPANY NAME
MAILING ADDRESS
IMPORTANT:
THE FOLLOWING INSTRUCTIONS
CITY
STATE
ZIP CODE
MUST BE ADHERED TO:
The Original Return must be filed with the Director, Division of Taxation
on or before March 1 annually and shall be
accompanied with a CHECK PAYABLE TO - " NJ DIVISION OF TAXATION -- INSURANCE TAX"
PLEASE REFER TO THE INSTRUCTIONS CONCERNING ELECTRONIC FUNDS TRANSFER (EFT) PAYMENTS.
Mail to:
Division of Taxation
PO Box 247
(200 Woolverton St.)
Trenton, NJ 08625-0247
ALSO
A duplicate return must be filed with the Commissioner of Banking and Insurance at the same time.
Mail to:
Department of Banking and Insurance
PO Box 325
(20 West State Street)
Trenton, NJ 08625-0325
WHEN COMPLETING THIS RETURN, PLEASE BE SURE TO FOLLOW THE GENERAL FILING INSTRUCTIONS ON PAGE 4.
ANNUAL REPORT
Statement of Premium Taxes and Other Obligations
Commissioner of Banking and Insurance, State of New Jersey :
Director, Division of Taxation, State of New Jersey :
The
incorporated or organized under the laws of New Jersey and with offices located at
MAILING ADDRESS OF OFFICE PREPARING RETURN
hereby submit the following statement for the calendar year ending December 31, 20
, as required by, and in accordance
with the New Jersey Revised Statutes Title 54 chapters 16, 17, 18 and 18A.
The actual address of the New Jersey Principal Office:
STREET, CITY, ZIP CODE
, which is located in
NAME OF MUNICIPALITY* AND COUNTY
*Please be sure to indicate the actual municipality and not the New Jersey mailing address.
Date of Incorporation or organized
Date first licensed in New Jersey
STATE OF
}
COUNTY OF
ss.
On this
day of
A.D. 20
before me
personally appeared
(INSERT SECRETARY OR U.S. MANAGER)
Insurance Company of
who being duly sworn according to law, on his oath did depose and say that the foregoing report is true and correct.
Subscribed and sworn to before me the
day and year aforesaid.
(INSERT SECRETARY OR U.S. MANAGER)
IMPORTANT:
THIS BLOCK MUST BE COMPLETED
FEDERAL EMPLOYER IDENTIFICATION
NUMBER
(OFFICIAL TITLE)
(NAME & TITLE OF PARTY TO CONTACT REGARDING THIS RETURN)
(PHONE NUMBER)
(EMAIL ADDRESS)
(SIGNATURE OF INDIVIDUAL PREPARING THIS RETURN)
(PREPARER'S IDENTIFICATION NUMBER)
(NAME OF TAX PREPARER'S EMPLOYER)
(EMPLOYER'S IDENTIFICATION NUMBER)
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