Revised Quarterly Surplus Lines Broker Reporting Forms and Procedures

Delaware Form SL-1925-Q-2012 Page 1 of 2 Original Report Amended Report Form SL-1925-Q Formerly Form SL-1917 STATE OF DELAWARE DEPARTMENT OF INSURANCE SURPLUS LINES BROKER QUARTERLY PREMIUM TAX SUMMARY REPORT FOR THE CALENDAR YEAR 2011, DUE MARCH 1, 2012 THIS FORM IS TO BE FILED BY, OR ON BEHALF OF, INDIVIDUAL SURPLUS LINES BROKERS ONLY. AGENCIES CANNOT TRANSACT BUSINESS AND SHOULD NOT SUBMIT THIS FORM. SURPLUS LINES (SL) BROKER INFORMATION AND MAILING ADDRESS Individual SL Broker Name: Individual Broker ID #: (DE Lic. #) Agency Name: Individual Broker NPN: Agency Address: Agency ID #: (DE Lic. #) City – State – Zip + 4: Tax Contact Name: Phone Tax Contact E-mail: Select Report Type: Q112 Due April 30, 2012 Q312 Due October 30, 2012 Q212 Due July 30, 2012 Q412 Due January 30, 2012 Questions should be directed to: Ann Fletcher Tax and Fees Coordinator PG, RRG & SL Specialist E-mail: Ann.Fletcher@state.de.us PART 1: The Federal Nonadmitted and Reinsurance Reform Act of 2010 (“NRRA”) became effective on July 21, 2011, and placed surplus lines taxation, regulation, and broker licensing authority under the exclusive oversight of the home state of the insured (see 18 Del. C. §1904(a)(9) for definition of home state). Delaware’s surplus lines law, Title 18, Chapter 19 was changed to conform to the NRRA. These changes apply to all surplus lines policies with an effective date on or after July 21, 2011. IMPORTANT: 2% premium tax is due on 100% of the policy premium, including fees, when Delaware is the home state of the insured. In accordance with 18 Del. C. §1925 and §1926, if Delaware is determined to be the home state of the insured, the entire policy premium must be reported to Delaware, and the amount of tax paid to Delaware must be calculated on the entire premium for the policy, not just the portion that applies to risks located within Delaware as was stipulated under the old surplus lines law. This is especially important in the case of a policy with risks in more than one state. DO NOT report premiums on this form unless Delaware is the home state of the insured. If Delaware is not the home state of the insured, premiums should be reported and taxes paid only to the state that is the home state of the insured. PART 1 – GROSS PREMIUMS AND TAX SUMMARY REPORT ONLY PREMIUMS ON SURPLUS LINES POLICIES FOR WHICH DELAWARE IS THE HOME STATE OF THE INSURED SINGLE-STATE POLICIES Enter number of single-state policies written: SECTION 1: Premiums Covering Risks in the State of Delaware ONLY 1a. Amount of Premiums Applicable to risks located within the state of DE: 1b. Less: Premiums returned on policies reported on Line 1a: (enter as negative) 1c. Net Amount of Premiums Applicable to risks Delaware only risks: MULTI-STATE POLICIES Enter number of multi-state policies written: SECTION 2: Premiums Covering Risks in Multiple States, including Delaware 2a. Amount of Premiums Applicable to risks located in the state of DE: 2b. Amount of Premiums Applicable to risks located in other states outside of DE:: 2c. Less: Premiums returned on policies reported on Lines 2a & 2b: (enter as negative) 2d. Net Amount of Premiums Applicable to multi-state risks: PREMIUM TAX CALCULATION SECTION 3: Premium tax at the rate of 2% is due on 100% of the policy premium, including fees. 3. Net Taxable Surplus Lines Premiums Written (add Lines 1c plus 2d) 4. Premium Tax Rate (2%) .02 5. TOTAL Premium Tax Due (Line 3 x Line 4): IMPORTANT: If there is an overpayment on Line 5, that amount may be carried into the next quarter and applied to tax liability for that quarter. If an overpayment remains at year-end, it should be so indicated on the annual tax report and a refund will be issued to the broker. 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 .02 0.00 Delaware Form SL-1925-Q-2012 Page 2 of 2 Individual SL Broker Name: Individual Broker ID #: (DE Lic. #) AFFIDAVIT All Premium Tax and Fees Reports shall be verified by the oath or affirmation of the reporting Surplus Lines Broker, duly administered by a person authorized to administer oaths. In the State of County of on this date , before me, (MMDDYYYY) the subscriber, personally appeared the surplus lines licensee listed above, who deposes and says that this report and all schedules are true, correct, and complete. Sworn to and subscribed before me this date. Signed this date: Sign Here Printed Name of SL Broker (as listed above) Signature of Reporting SL Broker Sign Here Signature Notary Public Notary Seal GENERAL INSTRUCTIONS For Part 1 and Part 2 on Page 1 PART 1: The federal Nonadmitted and Reinsurance Reform Act of 2010 (“NRRA”) became effective on July 21, 2011, and placed surplus lines taxation, regulation, and licensing authority under the exclusive oversight of the home state of the insured (see 18 Del. C. §1904(a)(9) for definition of home state). Delaware’s surplus lines law, Title 18, Chapter 19 was changed to conform to the NRRA. These changes apply to all surplus lines policies with an effective date on or after July 21, 2011. IMPORTANT: 2% premium tax is due on 100% of the policy premium, including fees, when Delaware is the home state of the insured. In accordance with 18 Del. C. §1925 and §1926, if Delaware is determined to be the home state of the insured, the entire policy premium must be reported to Delaware, and the amount of tax paid to Delaware must be calculated on the entire premium for the policy, not just the portion that applies to risks located within Delaware as was stipulated under the old surplus lines law. This is especially important in the case of a policy with risks in more than one state. Because the changes to the surplus lines law took affect in mid-year, for calendar year 2011 only, premium reporting on this form has been divided into sections, depending on the effective date of the policies. In addition, premiums for policies written after July 21, 2011, are being reported in separate groups based on where the risk is located. Please refer to the attached instructions and follow them carefully. For policies written after July 21, 2011, DO NOT report premiums on this form unless Delaware is the home state of the insured. If Delaware is not the home state of the insured, premiums should be reported and taxes paid only to the state that is the home state of the insured. SECTION 1 Lines 1a, 1b, and 1c: Report premiums written, minus premiums returned to policyholders, to give the net amount of taxable premiums written and having policy effective dates after July 21, 2011 for which DE is the home state of the insured. Report only the portion of the risks located in DELAWARE SECTION 2 Lines 2a, 2b, and 2c: Report premiums written, minus premiums returned to policyholders, to give the net amount of taxable premiums written and having policy effective dates after July 21, 2011 for which DE is the home state of the insured. Report only the portion of the risks located in OTHER STATES SECTION 3 Premium Tax Calculation Line 3 Taxable Premium: Add net premium from prior to July 21, 2011 (Line 1c) and net premium from after July 21, 2011 for which DE is the home state of the insured (Line 2c plus Line 2f) Line 4 Delaware’s tax rate is 2%. REMEMBER: Fees are included as taxable premium Line 5 Total tax due: Multiply Line 3 by Line 4. MAILING INSTRUCTIONS Quarterly Premium Summary Reports and payments must be received on or before the due dates, to avoid administrative penalties. Send this form along with a check payable to Delaware Insurance Department, to this address:  Delaware Insurance Department Attn: SURPLUS LINES SECTION 841 Silver Lake Blvd. Dover, DE 19904-2465