Surplus Line Producers Quarterly Tax Statement Form (Page 2 of 3) in pdf

Surplus Line Producers Quarterly Tax Statement Form Page 2

Producer Number:

Producer Name:

235535

Cain, Richard Dale

QUARTERLY RECAPITULATION BY INSURER

List all approved unauthorized insurers, foreign and alien, with whom surplis line coverage was placed and the taxable amount of

premium transacted with each insurer. All coverage placed is required to be with companies that have met the requirements of

L.R.S. 22§1262. Complete and attach additional copies of this same sheet, if additional space is needed.

NAIC

LATE TAXABLE

COMPANY NAME

TAXABLE PREMIUMS

NUMBER

PREMIUMS

AA-1122000

Underwriters at Lloyd's, London

$1,150.00

$0.00

A. SUBTOTAL OF PREMIUMS LISTED ON THIS PAGE

$1,150.00

$0.00

B. POLICY FEES OR TAXABLE FEES NOT INCLUDED IN THE ABOVE AMOUNTS

$50.00

$0.00

C. TOTAL TAXABLE PREMIUMS & FEES LISTED ON THIS PAGE

$1,200.00

$0.00

Producer Number:

Producer Name:

235535

Cain, Richard Dale

STATE: ____________________________________

PARISH OR COUNTY: ____________________________________

THE UNDERSIGNED ATTESTS THAT THIS IS A STATEMENT OF QUARTERLY GROSS PREMIUMS ON RISKS LOCATED IN

THE STATE OF LOUISIANA PLACED AS SURPLUS LINES, WITHOUT ANY DEDUCTIONS FOR DVIDENDS PAID OR

OTHERWISE CREDITED TO POLICYHOLDERS, AS REQUIRED BY TITLE 22, FOR THE QUARTER AND YEAR INDICATED

ON THIS FORM. THE UNDERSIGNED ALSO ATTESTS THAT THEY ARE A LICENSED SURPLUS LINES PRODUCER IN THE

STATE OF LOUISIANA AND THE TAX REPORTED ON THIS FORM REPRESENTS THE TRUE EXHIBIT OF NET PREMIUMS

AND TAXES OWED BY THEM IN LOUISIANA. ALSO, THE APPROVED UNAUTHORIZED INSURANCE COMPANIES, WITH

WHICH COVERAGE WAS PLACED, MEET THE REQUIREMENTS OF L.R.S. 22§1262 AND THAT ALL POLICIES HAVE BEEN

PROPERLY ENDORSED AND COUNTERSIGNED, PURSUANT TO L.R.S. 22§1258, TO THE BEST OF THE AFFIANT'S

KNOWLEDGE, INFORMATION, AND BELIEF.

See Required Signature Note Below ?????

_______________________________________________________

SURPLUS LINES PRODUCER OR AUTHORIZED COUNTERSIGNER

_______________________________________________________

DATE

Page 2

of 3

Revised (7/03)

THIS DOCUMENT IS EXEMPT FROM PUBLIC RECORDS LAW UNDER L.R.S. 44§4

Surplus Line Producers Quarterly Tax Statement Form Page 2

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