Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 6, app 2 - REPORT OF SURPLUS LINES INSURANCE

Year Ending December 31, 2

This report is to be filed with the Commissioner of Insurance, State of Wisconsin, Madison, Wisconsin 53702, on or before March 1, 2_____

Agent		Business address, including zip code			Date
Proposal No. and Date* (1)	Name of Insured (2)	Name of Insurance Company (3)	Contract Number (4)	Term and Effective Date (5)	Premium Charged (6)	3%** Premium Tax Collected (7)
*Proposals are to be numbered consecutively		. Premium Collected During Year .........................				$____________
** 1/2 of 1% for Ocean Marine Insurance		Tax Due @ 3%**-Total Column (7) .....................				$ _____________
		Amount Enclosed ................				$ ______________

Notes

Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 6, app 2

2011 Wisconsin Act 224 changed the tax rate for surplus lines insurance which is ocean marine insurance to the same 3% rate for all other surplus lines insurance. Any previous reference to a 1/2 of 1% rate for ocean marine insurance in this rule is not enforceable as that insurance is now taxed at the same 3% rate for all surplus lines insurance.