Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 6, app 1 - NOTICE OF DIRECTLY PLACED UNAUTHORIZED INSURANCE

To: Commissioner of Insurance

State of Wisconsin

P.O. Box 7873

Madison, WI 53707-7873

1. Name of Person or Organization Insured

2. Address of Insured

3. Contract Number

4. Effective Date

5. Expiration Date

6. Name and Address of Insurance Company

7. Description or Type of Coverage

8. Premium Charged

The undersigned certifies that this report is true and correct according to the best of his or her information, knowledge, and belief.

___________________

________, 2__________

Notes

Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 6, app 1

Amended by, Register December 2017 No. 744, eff. 1/1/2018

This report, pursuant to s. 618.42(2), Stats., must be filed with the Commissioner of Insurance within 60 days after effectuation of any new or renewal insurance contract independently procured from an unauthorized insurer. A separate report is required for each new or renewal insurance contract. A 3% Tax on the premiums charged for such contracts during the calendar year ending December 31 must be paid to the Commissioner on or before March 1 next succeeding.