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

• Library: Wisconsin Administrative Code
• Edition: 2023
• Currency: Current through December 26, 2023
• Citation: Wis. Admin. Code Office of the Commissioner of InsuranceIns 6.18 app 1
• Year: 2023

Year Ending December 31, 2

Unauthorized Insurance on Wisconsin Risks - Sections undefinedQualified insurers610.11 and undefinedTaxation of insurance written by unauthorized insurers618.43, 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

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)

...