Registration Form Insurance Premiums Tax (Page 3 of 3) in pdf

Registration Form Insurance Premiums Tax Page 3

Page 3

Part D: Registration Type

INSURANCE PROVIDER

(If selling insurance, related to risk occurring in the province, complete the following.)

Estimated annual sales in the province $___________________

Commencement date of business

(Month)

(Day)

(Year)

Commencement date of business in NL

(if different than above)

(Month)

(Day)

(Year)

SELF ASSESSOR

(If self- assessing retail sales tax ,on insurance premiums paid in relation to risk occurring in the province, complete the

following.)

Nature of Business:

(Month)

(Day)

(Year)

Date(s) of your policy premium

(Month)

(Day)

(Year)

PART E: CERTIFICATION

I hereby certify that, to the best of my knowledge and belief, the information provided on this form is accurate.

First Name

Last Name

Title

(Signature)

(Date)

Privacy and Confidentiality Notice

This information is collected for the purpose of the Department of Finance to process applications under the Revenue

Administration Act. All information you provide, both personal and business related, will be kept confidential and compliant with

the Access to Information and Protection of Privacy Act, 2015 ( ).

If you have any questions regarding privacy and confidentiality please contact the Tax Administration Division toll free at

1-877-729-6376.

P.O. Box 8720, St. John’s, NL, Canada A1B 4K1 Telephone 1-877-729-6376

Fax (709) 729-2856

Registration Form Insurance Premiums Tax Page 3