Establishing secure connection… Loading editor… Preparing document…
Navigation

Fill and Sign the State of Indiana Quarterly Premium Tax Form

Fill and Sign the State of Indiana Quarterly Premium Tax Form

How it works

Open the document and fill out all its fields.
Apply your legally-binding eSignature.
Save and invite other recipients to sign it.

Rate template

4.5
49 votes
THE AMERICAN E XPRESS® AIR MILES®* CREDIT CARD Please print full name (must not exceed 20 spaces). Spell your last name completely. Applicants must be residents of Canada. Please note that your current annual income must be at least $15,000. If you are already an American Express Cardmember please provide your Card Number: J40 V1 AAVSAMPDFE 501 NPU Are you currently an AIR MILES Collector? YES ❏ NO ❏ If you are already an AIR MILES Collector please provide your Collector Number: A P P L I C AT I O N F O R M ( Home Address Apt. # Date of Birth MM/DD/YYYY (mandatory) ❏ Yes City Province Social Insurance Number (optional) Providing social insurance number can expedite application process. ❏ No Self Employed? Postal Code Email Address (optional) ( Employer Name Describe Occupation ) Home Phone ) $ / Year Personal Annual Income Business Phone ( Employer Address City Province Postal Code ) Cell Phone (Optional) B A L A N C E T R A N S F E R R E Q U E ST ❏ YES, please transfer my account balance from my retail or financial institution card to my American Express Credit Card.† I understand such transfer is subject to approval. Amount Name of Retail/Financial Institution Credit or Charge Card Account Number Minimum transfer amount $100. You may not transfer more than your available American Express credit limit. Please see Balance Transfer section for complete details. Amount Name of Retail/Financial Institution Credit or Charge Card Account Number † M AY W E S E N D YO U F R E E S U P P L E M E N TA RY C A R D S ? Please print full name (must not exceed 20 spaces). A. Name (first, middle initial, last) B. Name (first, middle initial, last) ❏ Same as Basic Applicant’s Home Address Home address ❏ Same as Basic Applicant’s Home Address Apt. # City Date of Birth MM/DD/YYYY (mandatory) Province Postal Code Home address Relationship to Basic Applicant ( Describe Occupation Apt. # City Date of Birth MM/DD/YYYY (mandatory) ) Province Postal Code Relationship to Basic Applicant ( Home Phone Describe Occupation ) Home Phone PLEASE REVIEW THIS COMPLETE APPLICATION FORM, TERMS AND CONDITIONS AND DISCLOSURE FOR IMPORTANT INFORMATION. By signing below, you certify that you have read, met and agreed to all the terms and conditions and disclosure included with this application. You represent and agree that the account will not be used by or on behalf of any third party other than an approved Supplementary Cardmember. You acknowledge that the Consent to Use of Personal Information included with this application includes the sharing and exchange of reports and information about you with credit reporting agencies, credit bureaus and others. P L E A S E S I G N B E LOW X BASIC CARD APPLICANT X Date SUPPLEMENTARY CARD APPLICANT A Date X SUPPLEMENTARY CARD APPLICANT B Date To ensure that we get your application today, please fax it to us at 1-800-306-8863. AAVSAMPDFE 02/08 DISCLOSURE (as at 02/08) Purchases and Funds Advances Your applicable Annual Interest Rate will be: If your Account Payment Record in the Review Period shows: And will continue to apply as follows: PREFERRED RATE • 18.50% for purchases and funds advances • No more than one Missed Payment; and • You were at the Preferred Rate in the last Review Period or you are at the end of 12 billing periods in which the Standard Rate or Basic Rate applied • Subject to your Account Payment Record in later Review Periods STANDARD RATE • 19.99% for purchases and funds advances • Two separate Missed Payments • Whenever the Standard Rate or Basic Rate applies, the rate will not be decreased for at least 12 billing periods from the effective date of the rate BASIC RATE • 25.99% for purchases and funds advances • One Missed Payment remains unpaid for two (or more) consecutive billing periods, or • Three (or more) separate Missed Payments • Each billing period, rate is subject to increase to the Basic Rate as determined by your Account Payment Record in the Review Period What Annual Interest Rate applies to Introductory Rate Offers for Balance Transfers and Other Special Rate Offers? During the first 6 months of your Card membership only, an introductory annual interest rate of 3.99% applies to any balance transfers. We may, but are not obligated to, make other special rate offers at any time. If you have one Missed Payment at any time after the date that the first balance transfer or the first special rate offer transaction is posted to your account, that introductory or special rate offer will be revoked. After the first 6 months of Card membership or after the special rate offer expires, or if the introductory or special rate offer is revoked, balance transfers or the balance that is subject to the special rate offer will be treated in the same way as purchases as set out above, including the applicable annual interest rate that applies to purchases at that time. Definitions and Other Important Information • At the end of each billing period, we will review your Account Payment Record in the Review Period to determine your rate for the next billing period. • “Account Payment Record” means your record of Missed Payments. • “Review Period” means the 12 consecutive billing periods ending on the last day of the current billing period.• “Missed Payment” means we did not receive the minimum monthly payment by the date of the next billing statement. • Rates and criteria are subject to change. • Interest is calculated daily and is charged to your account on the last day of the billing period. Interest on a purchase applies from and including the transaction date or from and including the first day of the billing period in which the purchase is first charged to your account, if that date is later, until the day we receive payment in FULL. However, there is an interest grace period for purchases of 21 days from the Closing Date on your statement if we have received payment in FULL by the payment due date of the New Balance shown on your statement for both that billing period and the previous billing period. On a funds advance, Amex cheque and balance transfer there is no interest grace period and interest is always charged from and including the transaction date until the day we receive payment in FULL. • The minimum payment is (i) 3% of the outstanding balance as of the statement closing date or $10 (or the entire new balance if it is less than $10), plus (ii) any previously billed minimum payments that remain unpaid on the closing date of the statement. • FEES AND CHARGES - Annual Fees: No annual fees. Non Interest Charges: Funds Advance Fee: $2.75 each; Dishonoured Payment Fee: $25.00 each; Statement Reprint Fee: $3.00 per statement; Front Of The Line® Fee: $3.50 per ticket; Overlimit Fee: $20.00 will be charged at the end of a billing period if you are over your credit limit at any time during that billing period. Charges made in foreign currencies: The conversion commission is 2.5% for each charge. Except as otherwise noted, these fees and commission will be charged when they are incurred and will be included on the next statement. TERMS AND CONDITIONS You ask that an American Express Credit Card Account be opened in the name of the Basic Applicant and cards (“Card(s)”) issued as requested, and that Amex Bank of Canada (“we”, “our”, “us”) renew and replace them until they are cancelled. You agree to be bound by the Cardmember Agreement and disclosures (“Agreement”) received with each of the Card(s), and understand that if you do not wish to be bound by the Agreement, the Card(s) must be returned. You understand that signing, using or accepting Card(s) will constitute acceptance of the Agreement. IF YOU ARE THE BASIC APPLICANT YOU WILL BE THE BASIC CARDMEMBER AND YOU AGREE TO BE LIABLE FOR ALL CHARGES TO THE ACCOUNT, WHETHER ON A BASIC OR ANY SUPPLEMENTARY CARD(S). A SUPPLEMENTARY CARDMEMBER IS AN AUTHORIZED USER OF THE CARD ACCOUNT BUT IS NOT LIABLE FOR AMOUNTS OWING ON THE ACCOUNT. You certify that the information contained on this application and all future information you provide will be true, complete and correct. You certify that you are of the age of majority and are not bankrupt or insolvent or subject to any bankruptcy or insolvency proceedings. Language (for Quebec residents only/aux résidents du Québec seulement) By completing this application in English, you confirm that you wish this application, the Agreement and all communications, including statements, notices and other documents from us, our affiliates and merchants that honour the Card to be English until you otherwise advise us. En complétant cette demande en anglais, vous confirmez que vous désirez que cette demande, la convention et toutes communications, y compris les relevés, avis et autres documents, provenant de nous, de sociétés membres de notre groupe et de marchands acceptant la Carte, soient rédigées en anglais, sauf avis contraire de votre part. Rewards You acknowledge that (i) the AIR MILES Reward Program (“Program”) is operated by Loyalty Management Group Canada Inc. (“LMG”) which is solely responsible for the Program and its operation; (ii) eligibility for AIR MILES reward miles and rewards is subject to the terms and conditions of the Program; (iii) the Program may be changed or terminated by LMG at any time; (iv) the arrangement Amex Bank has with LMG for the issue of AIR MILES reward miles for net eligible purchases on the Card may be changed or terminated at any time, and (v) if you are not approved for an American Express AIR MILES Credit Card, you can apply separately to become an AIR MILES Collector, if not already enrolled in the Program. AIR MILES reward miles issued through use of a Supplementary Card will only be credited to the Basic Cardmember’s American Express AIR MILES Credit Card account. Balance Transfer The following additional terms and conditions apply to balance transfers: • Subject to our approval of any balance transfer, the minimum balance transfer amount is $100 and the maximum is your available credit limit. • You authorize and direct us to make payment of the balance transfer amount to the other card issuer on your behalf and to transfer the balance to your Card account. • You will be liable to repay the balance transfer and applicable interest. • Interest on balance transfers is assessed from the transaction date. • Payments are applied to balance transfers before purchases but after funds advances and are first applied to balance transfers with the lowest interest rates. • When you transfer and carry a balance and the new balance shown on your monthly statement is not paid in full, there will no longer be an interest grace period for purchases and interest will apply to all charges at the applicable interest rate(s) for your account. See “DISCLOSURE” section for applicable interest rates. • Balances must be transferred from recognized card accounts such as other financial institutions, retailers and oil companies. Balances cannot be transferred to or from another account with us. • You certify that the other card account is in good standing and you agree to maintain it in good standing until the balance transfer is completed. You authorize us to verify the status of the other card account. • Points, miles, cash back and other rewards (as applicable) are not earned on balance transfers. • Supplementary Cardmembers are not permitted to transfer balances. • We reserve the right to refuse to process any balance transfer for any reason at our sole discretion, including, without limitation, if: you have missed any minimum monthly payments, you have any dishonoured payments, you have exceeded your credit limit, the balance transfer request is not properly completed, your account is not in good standing, the other card is not reported on the credit bureau or we become aware of any adverse credit information. AAVSAMPDFE 02/08 • We are not responsible for any charges to or any other matters related to the other card account, for example charges resulting from any delay in processing the balance transfer. Balance transfers may take 3 to 5 business days to process. PRIVACY NOTICE In this Notice, the words “we”, “our” and “us” mean Amex Bank of Canada (“Amex Bank”), its affiliates (including Amex Canada Inc., a provider of travel related services), and their agents and service providers (acting on their behalf). “Personal information” is any information which relates to an individual and allows that individual to be identified (“Information”). Consent to Use of Personal Information We collect, disclose, use and process Information: (1) to consider initiating and to initiate, maintain and develop our relationship with you in connection with our offering products and services generally, including helping us to understand the current and future needs of our customers and to otherwise analyze and manage our business; (2) to administer billing and accounting services and security measures in relation to your business with us; (3) to monitor your transactions; (4) to evaluate your credit standing; (5) to share and exchange reports and Information with credit reporting agencies, credit bureaus and/or any other person, corporation, firm or enterprise with whom you have or propose to have a financial relationship and to use other third party databases (including registries and licensing authorities) or references provided by you to obtain or verify Information about your financial circumstances, your background or to identify you; when you apply to be a Supplementary Cardmember, such sharing, exchange or use will be limited to obtaining or verifying Information about your background and to identify you; (6) as permitted by or to comply with legal and regulatory requirements; (7) to promote and to market products and services offered by us or other well established companies, including by means of direct marketing through ordinary mail, e-mail, telephone or other available communication channels; we may also send you special offers with your statements or in separate mailings that include personalized cheques to access your Card account (“Amex Cheque Offers”); and (8) where the provision of services or benefits provided to you in relation to the account are offered by or include the participation of third party suppliers, to our sharing and exchanging with such third party suppliers and their agents and service providers any Information reasonably required for the provision of the service or benefit including if this application is approved, (i) providing Loyalty Management Group Canada Inc., or its agents (“LMG”) with the Basic Applicant’s name, billing address and the Collector Account Number shown on this application or, if no AIR MILES Collector Number is shown on this application, the Basic Applicant’s name and address for enrollment in the AIR MILES Reward Program (the “Program”), and (ii) sharing and exchanging with LMG any Information reasonably required for the Program. If provided, your Social Insurance Number will be used to match credit bureau/reporting agency Information to help ensure the accuracy of the Information collected and reported. If you provide an e-mail address, we may also send customer service and collection notices. You agree that we may monitor and/or record any of your telephone calls with us for servicing accuracy, quality assurance and training. We may use Information in our records for as long as it is needed for the purposes described above even after our relationship with you has ended. Certain consents are mandatory and cannot be withdrawn. For example, once you have a card or other credit product, you may not withdraw your consent relating to ongoing collection and disclosure of credit information. This is necessary to maintain the integrity of the credit granting process. You consent to our collection, disclosure, use and processing of Information about you for the purposes described above. You authorize third parties to give us the Information for these purposes. If you provide us with Information about any other individual, you confirm that the individual (i) has consented to our collection, disclosure, use and processing of that Information for these purposes as reasonably required (provided that all these purposes will apply to Supplementary Cardmembers), and (ii) authorizes third parties to give us the Information for these purposes. You may at any time refuse or withdraw your consent under (7) completely or you may select from any partial consent options we may make available by calling 1-800-869-3016. For example, you may choose not to receive Amex Cheque Offers. Your request will be processed promptly but may not be captured for promotions already in progress. This will not limit information we may provide you when you contact us. Nature of Information Collected The Information we collect from time to time may include: • Information to identify you such as name, date of birth, contact information, driver’s license or other identification, and your background (for example, occupation) as required by law; • Financial Information such as income, assets, payment history and credit worthiness; • Information for the provision of products and services (for example, language and other preferences). We monitor transactions that may be of risk from a credit, fraud or money laundering and terrorist financing perspective. Privacy Code To obtain more information about our policies and procedures in protecting your privacy, you can visit our website at www.americanexpress.ca/privacy or call us at 1-800-869-3016 to request a copy of our Privacy Code. If your application is approved, a copy of our Privacy Code will be sent with your Cardmember Agreement. Our Privacy Code includes additional illustrative descriptions and examples to help you understand the nature of the information we collect and how it relates to many of the purposes in this Notice; how to request access and correction to your Information held by us; and additional details about your consent rights. Special AIR MILES Program Provisions If you are not an AIR MILES Collector, the full terms and conditions of the AIR MILES Reward Program, including the AIR MILES Privacy Commitment will be provided to you under separate cover. For complete Program Terms and Conditions and information about the AIR MILES Privacy Commitment, visit www.airmiles.ca or call the AIR MILES Service Centre at 1-888-AIR-MILES (1-888-247-6453) (in Toronto (416) 226-5171). Disclosure, terms and conditions and other information accurate as at date shown and is subject to change. For current information, please call 1-800-869-3016, 24 hours a day, 7 days a week. ® : Trademarks of AIR MILES International Trading B.V. Used under license by Loyalty Management Group Canada Inc. and Amex Bank of Canada. ®: Used by Amex Bank of Canada under license from American Express. *

Useful Advice on Preparing Your ‘State Of Indiana Quarterly Premium Tax Form’ Online

Are you fed up with the inconvenience of handling paperwork? Look no further than airSlate SignNow, the premier electronic signature platform for individuals and businesses. Bid farewell to the lengthy process of printing and scanning documents. With airSlate SignNow, you can effortlessly finalize and sign paperwork online. Utilize the robust features included in this user-friendly and cost-effective platform and transform your method of document management. Whether you need to authorize forms or gather signatures, airSlate SignNow manages it all effortlessly, with just a few clicks.

Adhere to this comprehensive guide:

  1. Sign in to your account or register for a free trial with our service.
  2. Click +Create to upload a file from your device, cloud storage, or our template library.
  3. Open your ‘State Of Indiana Quarterly Premium Tax Form’ in the editor.
  4. Click Me (Fill Out Now) to complete the form on your end.
  5. Add and designate fillable fields for other participants (if necessary).
  6. Proceed with the Send Invite settings to solicit eSignatures from others.
  7. Save, print your copy, or convert it into a multi-use template.

No need to worry if you need to work with your colleagues on your State Of Indiana Quarterly Premium Tax Form or send it for notarization—our solution offers everything you need to accomplish such tasks. Create an account with airSlate SignNow today and elevate your document management to new levels!

Here is a list of the most common customer questions. If you can’t find an answer to your question, please don’t hesitate to reach out to us.

Need help? Contact Support
State of indiana quarterly premium tax form pdf
Indiana Department of Insurance Submission Portal
Roy Eft Indiana Department of Insurance
Indiana Department of Insurance case search
760 iac 1-18-20(2)
Indiana Insurance Code
Indiana Department of Insurance jobs
Indiana Department of Insurance email address
Sign up and try State of indiana quarterly premium tax form
  • Close deals faster
  • Improve productivity
  • Delight customers
  • Increase revenue
  • Save time & money
  • Reduce payment cycles