Louisiana Department of Insurance Surplus Line Producers Quarterly Tax Statement Form 1265 A

LOUISIANA DEPARTMENT OF INSURANCE
SURPLUS LINE PRODUCER’S QUARTERLY TAX STATEMENT
FORM 1265 A

(For 4th Quarter and Annual Certification)

Insurance Premium Tax Division
P. O. Box 94214, Baton Rouge, LA 70804-9214

THIS DOCUMENT IS EXEMPT FROM PUBLIC RECORDS LAW UNDER L.R.S. 44:4

This form stating gross premiums on single state (all within Louisiana) risks placed as surplus lines, must be filed in accordance with LA. R.S. 22:439A(1), which states in part:

“On or before March first, June first, September first, and December first of each year, each surplus lines broker shall transmit to the commissioner of insurance a surplus lines tax report for the prior calendar quarter”.

In addition, the 4.85% surplus lines tax must be paid as provided by L.R.S. 22:439A(2), and if any, a penalty of 10% of the tax is due and payable to the Commissioner of Insurance as outlined in LA.R.S. 22:440.

The quarters and due dates are as follows:

Fourth Quarter: October 1 through December 31    Due March 1

CALCULATION OF TAXABLE PREMIUMS, TAX DUE, AND LATE PENALTY

NOTE: If statement is filed after the quarter’s due date, all premiums on that statement should be reported as LATE.

CHECK IN THE AMOUNT OF $ payable to the Commissioner of Insurance, State of Louisiana is attached hereto.

FOR DEPARTMENT USE ONLY, DO NOT WRITE IN THIS SPACE: REVIEWED BY ______ DATE ______ RECEIPT NUMBER______

QUARTERLY RECAPITULATION BY INSURER

List all approved unauthorized insurers, foreign and alien, with whom surplus line coverage was placed and the taxable amount of premium transacted with each insurer. Negative premiums are not considered late (e.g. for policy cancellations) and must be entered in the Taxable Premiums Column, not the Late Taxable Premiums Column.

ANNUAL CERTIFICATION (Check One Box)

I ATTEST THAT NO BUSINESS WAS DONE UNDER THIS LICENSE IN THIS CALENDAR YEAR.

I ATTEST THAT BUSINESS WAS DONE UNDER THIS LICENSE THIS YEAR AND THAT THE SURPLUS LINES TAXES HAVE BEEN PROPERLY REPORTED AND PAID IN THIS 4TH QUARTER AND PRIOR QUARTERS.

STATE:

PARISH OR COUNTY:

THE UNDERSIGNED ATTESTS THAT THIS IS A STATEMENT OF QUARTERLY GROSS PREMIUMS ON RISKS LOCATED IN THE STATE OF LOUISIANA PLACED AS SURPLUS LINES, WITHOUT ANY DEDUCTIONS FOR DIVIDENDS PAID OR OTHERWISE CREDITED TO POLICYHOLDERS, AS REQUIRED BY TITLE 22, FOR THE QUARTER AND YEAR INDICATED ON THIS FORM. THE UNDERSIGNED ALSO ATTESTS THAT THEY ARE A LICENSED SURPLUS LINES PRODUCER IN THE STATE OF LOUISIANA AND THE TAX REPORTED ON THIS FORM REPRESENTS THE TRUE EXHIBIT OF NET PREMIUMS AND TAXES OWED BY THEM IN LOUISIANA. ALSO, THE APPROVED UNAUTHORIZED INSURANCE COMPANIES, WITH WHICH COVERAGE WAS PLACED, MEET THE REQUIREMENTS OF L.R.S. 22§435 AND THAT ALL POLICIES HAVE BEEN PROPERLY ENDORSED AND COUNTERSIGNED, PURSUANT TO L.R.S. 22§433, TO THE BEST OF THE AFFIANT’S KNOWLEDGE, INFORMATION, AND BELIEF.

FILING INSTRUCTIONS