Forms with instructions for semiannual tax report filings by surplus lines agents

Issued and entered December 11, 1981 by Nancy A. Baerwaldt, Commissioner of Insurance

Section 500.1905(3)(e) of the Michigan Insurance Code requires that the surplus lines licensee " . . .file with the commissioner, not later than February 15 and August 15 annually, a sworn statement of the charges for insurance procured or placed, and the amounts returned on the insurance cancelled, under the license, for the preceding 6 month period ending December 31 and June 30, respectively, and at the time of filing the statement, paying to the commissioner a tax on premiums computed pursuant to Section 440."

The tax in insurance premiums is computed as follows:

3% of all property insurance premiums
2% of all casualty insurance premiums
2.7% of all multiple peril insurance premiums

The elected FORM (812301) should be completed and returned to this office with your tax payment postmarked no later than February 15 or August 15 of each year. Your check or money order should be made payable to the State of Michigan. Surplus Lines licensees who did not transact surplus lines business during a reporting period are not required to submit a report for that period.

Any questions regarding your report should be directed to the Michigan Insurance Bureau, Surplus Lines Unit, Post Office Box 30220, Lansing, Michigan 48909, telephone number (517) 373-0220.

SURPLUS LINES AGENT'S SEMIANNUAL TAX REPORT

Licensee ______________
Address _________________

Telephone
Number _______ Contact Person _________

I swear that, to the best of my knowledge, the following is a true statement of the charges for insurance procured or placed, and the amounts returned on the insurance cancelled, under my surplus lines license for the preceding 6 month period ending ___ :

Total Net Premium
Total Tax Due
Less Tax Paid
Balance Due

________________
Authorized Agent

_______
Date

_____________ Signed and Sworn to before me this day of PRINT AGENT'S NAME _____ , 19 __ , County of _____ my commission expires