Kansas Insurance Department

ANNUAL PREMIUM TAX STATEMENT

For Risk Retention Groups not Chartered in the State of Kansas.

The following is a full and complete statement of all premiums received, of whaever nature, whether in cash, notes, or credits, by:

Name of Risk Retention Group in the state of Kansas:
NAIC Co No
FEIN#

during the previous year ending December 31. Report is DUE by March 1 annually

1. Direct premiums on all risks written (Exhibit of Premiums Written - Business in Kansas during the Year $

2. Plus finance, service or other carrying charges assessed by the company or its agents not included in lines 1 to 32 as reported on the Exhibit of Premiums and Losses - Business in Kansas During the Year $

3. Total (Lines 1 and 2) $

4. Less dividends paid (Col. 4 or Exhibit of Premiums Written - Business in Kansas During the Year $

5. Net taxable premiums (Line 3 less Line 4) $

6. Tax due at 6% (Lines 5 x 6%) $

7. Plus any additional amounts due $

8. Net Tax Due (Line 6 plus Line 7) $

9. Tax due (no commas) $

Name, Email & Telephone Number of Individual Reponsible for Completion of Form:
President and Secretary
being duly sworn on oath say that they are the President and Secretary repsectively of the: (Full name of Risk Retention Group)
City State
Authorized to transact business as a Risk Retention Group in the State of Kansas during the year and that the under the penalty of perjury under the laws of the State of Kansas this statement and all submitted forms include all premiums received on all risks written in the State of Kansas, without deductions except as herein set forth.
President
Secretary
Date
Paper checks are no longer accepted.
If you have any questions reporting business, please feel free to contact us by email at kdoi.rf@ks.gov

STATE OF KANSAS ANNUAL REVIEW FOR RISK RETENTION GROUPS

Name of Risk Retention Group
RRG's FEIN
Statutory Home Address
Mailing Address
Administrative Address

General Contact Person:
Name
Email Address
Phone Number
Officers and Directors: Please list name and position of each officer/director of group. If not enough, space please email the list to kdoi.rf@ks.gov
Name Position
Name Position
Name Position
Agent(s): List name, address and National Producer Number of the agent(s) or broker(s) responsible for marketing the group's insurnace. If not enough space, please email the list to kdoi.rf@ks.gov
Name Address NPN#
Name Address NPN#
Name Address NPN#

The Group offers the following classification(s) of liability insurance:

Completed By: Title
Phone Number Date
Email Address