Wis. Admin. Code Office of the Commissioner of InsuranceIns 6.19 app 2 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 6.19 app 2
• Year: 2023

Year Ending December 31, 2

Directly Placed Unauthorized Insurance - Sections undefinedDirect procurement of insurance618.42 and undefinedTaxation of insurance written by unauthorized insurers618.43, Wisconsin Statutes

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

Person or Organization Insured			Address, including zip code			Date
Contract Number (1)	Effective Date (2)	Expiration Date (3)	Name and Address of Insurance Company (4)	Description or Type of Coverage (5)	Premium Charged (6)	3% Tax on Premium* (7)
*1/2 of 1% for Ocean Marine Insurance			Premium Charged- Total Column (6) ...	...................	$ _________
Tax Due @ 3%*- Total Column (7) ...	...................	$ _____________
Amount Enclosed ...	...................	$ ___________
The undersigned certifies that this report is true and correct according to the best of his or her information, knowledge and belief.
_______________________ _____________, 2 ______

Person or Organization Insured

Address, including zip code

Date

Contract Number (1)

Effective Date (2)

Expiration Date (3)

Name and Address of Insurance Company (4)

Description or Type of Coverage (5)

Premium Charged (6)

3% Tax on Premium* (7)

*1/2 of 1% for Ocean Marine Insurance

Premium Charged- Total Column (6) ...

...................

$ _________

Tax Due @ 3%*- Total Column (7) ...

...................

$ _____________

Amount Enclosed ...

...................

$...