Fill and Sign the Standard Form Subcontract Agreement

Department of Revenue Services State of Connecticut PO Box 2990 Hartford CT 06104-2990 (REV. 12/02) Form 115AR Report of Procurement, Continuance, or Renewal of Insurance with Unauthorized Insurer Purpose: Use this form to report insurance coverage obtained from an unauthorized insurer. File this report with the Commissioner of Revenue Services within 60 days after the date insurance is procured, continued, or renewed with any unauthorized insurer. A separate report is required for each new or renewed insurance contract. You must also file Form 115A, Premium Tax Return, and pay a 4% tax on the premium charged for the insurance during the calendar year, on or before March 1 of the following calendar year. Enter your Connecticut Unauthorized Insurance Tax Registration Number, if any: Name and Address of Insured First Name and Middle Initial Address Last Name Number and Street PO Box City, Town, or Post Office State First Name and Middle Initial Last Name Address ZIP Code Number and Street City, Town, or Post Office PO Box State ZIP Code Name and Address of Insurer Insurer’s Name Address Number and Street City, Town, or Post Office PO Box State ZIP Code Insurance Information Contract Number ........................... Premium Charged ......................... $ Effective Date .......... / / Expiration Date ........ / / General Description of Coverage Subject of the Insurance Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) and, to the best of my knowledge and belief, it is true, complete, and correct. I understand that the penalty for willfully delivering a false return to DRS is a fine of not more than $5,000, or imprisonment for not more than five years, or both. The declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge. Signature of Principal Officer Date Print Name of Principal Officer Title Daytime Telephone Number ( Sign Here Keep a copy for your Paid Preparer’s Signature Date ) Preparer’s SSN or PTIN records. Firm’s Name, Address, and ZIP Code FEIN X