Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 6, app 1
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 Insurance, ch. Ins 6, 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.