Wisconsin Administrative Code
Office of the Commissioner of Insurance
Chapter Ins 6 - General
Appendix 1 - PREMIUM TAX REPORT
Year Ending December 31, 2
Unauthorized Insurance on Wisconsin Risks - Sections 610.11 and 618.43, Statutes
This report is to be filed with the Commissioner of Insurance, State of Wisconsin, Madison, Wisconsin 53702, on or before March 1, 2 . ___
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Insurance Company |
Address, including zip code |
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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) |
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*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) ................... |
$________ |
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**2% for Ocean Marine Insurance |
Tax Due @ 5%**-Total Column (5) |
$________ |
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Amount Enclosed ................... |
$________ |
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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. |
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________________________ Name |
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___________________ Title Date |
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2011 Wisconsin Act 224 changed the penalty tax rate for surplus lines insurance which is ocean marine insurance to the same 5% penalty rate for all other surplus lines insurance. Any previous reference to a 2% penalty rate for ocean marine insurance in this rule is not enforceable as that rate is now the same 5% penalty rate for all surplus lines insurance.
