Wis. Admin. Code Office of the Commissioner of InsuranceIns 6.17 app 1 - SURPLUS LINES INSURANCE PROPOSAL

Name and address of applicant Date

Dear: Proposal No.

You have asked that I procure the following insurance coverage on your behalf:

Type of Insurance Limits of Coverage

I can procure the coverage desired from the following insurer(s) at the premium listed:

Insurer(s) - Name and Address % of Total Risk

Premium Quoted

This insurance is with an insurer which has not obtained a certificate of authority to transact a regular insurance business in the state of Wisconsin, and will be issued and delivered as a surplus lines coverage pursuant to s. 618.41, Stats. The insurance is regulated by the Commissioner of Insurance only as provided in ss. 618.41 and 618.43, Stats. Section 618.43(1), Stats., requires payment by the policyholder of a 3% tax on gross premium (except for Ocean Marine Insurance on which the tax is one-half of 1%). The tax in this instance amounts to $ . If the above transaction is not satisfactory, please advise immediately.

Sincerely yours,

______________________________________________

Name and address of licensed surplus lines agent

Notes

Wis. Admin. Code Office of the Commissioner of InsuranceIns 6.17 app 1

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 ½ 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.