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

Surplus Line Producers Quarterly Tax Statement Form Page 3

FILING INSTRUCTIONS

ALL Louisiana licensed surplus lines producers until license is cancelled, revoked, or expires (even if

Who Must File This Form?

there are no premiums to report).

First Quarter: June 1

Third Quarter: December 1

Due Dates:

Second Quarter: September 1

Fourth Quarter: March 1

This statement is considered LATE if postmarked by the U.S. Postal Service later than the due dates

specified above and on the front of this form. If sent through a service other than the U.S. Postal Service

Late Statements:

without a postmark, the statement will be considered LATE if received more than one day after the due

date.

Mailing Address: P.O. Box 94214, Baton Rouge, LA 70804-9214

Filing Address:

Physical Address: 1702 North 3rd Street, Baton Rouge, LA 70802

Phone: (225) 342-1012

Fax: (225) 342-9708

How to Contact Us:

E-Mail: taxdivision@ldi.state.la.us

If the holder of the Louisiana surplus lines producer's license filing this statement is an individual, that

individual must sign this statement.

Required Signature:

If the holder is any entity other than an individual, their authorized countersigner must sign this statement.

The Louisiana Department of Insurance may convert your payments by check to an electronic Automated

Clearinghouse (ACH) debit transaction. This means that your account may be debited the day your check

Payment Notice

is received by the Louisiana Department of Insurance. Although the debit transaction will appear on your

bank statement, your check will not be returned to your bank. If the electronic fund transfer cannot be

processed for technical reasons, you authorize us to process the copy of your check.

Page 3

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 3