Wis. Admin. Code Ins § 6.18 app. 1

Current through April 29, 2024
Appendix 1 - PREMIUM TAX REPORT

Year Ending December 31, 2

Unauthorized Insurance on Wisconsin Risks - Sections 610.11 and 618.43, Statutes

This report is to be filed with the Commissioner of Insurance, State of Wisconsin, Madison, Wisconsin 53702, on or before March 1, 2 . ___

Insurance Company

Address, including zip code

Numbers or

Names of Risks

(1)

Type of

Coverage

(2)

Name(s) and address(es) of Wisconsin

agent(s) who assisted in

procurement

(3)

Total

Premium

Received*

(4)

5% Tax on Total

Premium**

(5)

*Include all premium which can be allocated to a Wisconsin exposure, excluding move-in business and business placed with your company by a Wisconsin Surplus Lines agent

Premium Income from Wisconsin Risks- Total Column (4) ...................

$________

**2% for Ocean Marine Insurance

Tax Due @ 5%**-Total Column (5)

$________

Amount Enclosed ...................

$________

The undersigned, as an officer of the above-named insurance company, certifies that the report is true and correct according to the best of his or her information, knowledge, and belief.

________________________

Name

___________________

Title

Date

Wis. Admin. Code Office of the Commissioner of InsuranceIns 6.18 app 1

2011 Wisconsin Act 224 changed the penalty tax rate for surplus lines insurance which is ocean marine insurance to the same 5% penalty rate for all other surplus lines insurance. Any previous reference to a 2% penalty rate for ocean marine insurance in this rule is not enforceable as that rate is now the same 5% penalty rate for all surplus lines insurance.