Quarterly Statement
Quarterly Statement NAIC Company Code: ________________ NAIC Group Code: ________________ Employer’s ID: ________________ In Accordance with Section 603 of Chapter 25, Title 22 of the Virgin Islands Code To the Commissioner of Insurance of the United States Virgin Islands: The ___________________________________________________________________________ (Name of Company) of ________________________________, State of _______________________________ (Location of Home Office) Date Organized __________________ Date Admitted to the Virgin Islands ______________________ Capital Stock Authorized _________________ Paid in Capital to Date __________________________ Lines of Coverage being Written in the Virgin Islands ___________________________________________ 1) Losses incurred but not reported: $ 2) Amounts actually paid policyholders on Losses: $ 3) Amounts paid policyholders as dividends: $ 4) Amounts of Gross Premiums received or contracted for: Quarter ending: _________________________ $ 5) Amounts paid policyholders as returned Premiums: ($ ) 6) Amounts of Reinsurance Premium Received f …
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Quarterly Statement NAIC Company Code: ________________ NAIC Group Code: ________________ Employer’s ID: ________________ In Accordance with Section 603 of Chapter 25, Title 22 of the Virgin Islands Code To the Commissioner of Insurance of the United States Virgin Islands: The ___________________________________________________________________________ (Name of Company) of ________________________________, State of _______________________________ (Location of Home Office) Date Organized __________________ Date Admitted to the Virgin Islands ______________________ Capital Stock Authorized _________________ Paid in Capital to Date __________________________ Lines of Coverage being Written in the Virgin Islands ___________________________________________ 1) Losses incurred but not reported: $ 2) Amounts actually paid policyholders on Losses: $ 3) Amounts paid policyholders as dividends: $ 4) Amounts of Gross Premiums received or contracted for: Quarter ending: _________________________ $ 5) Amounts paid policyholders as returned Premiums: ($ ) 6) Amounts of Reinsurance Premium Received from Unauthorized Reinsurers (Attach Listing of Named Companies & Amounts): $ 7) Amounts of Reinsurance Premium Received from Authorized Reinsurers (Attach Listing of Named Companies & Amounts): ($ ) Taxes Due (5% of the net total of lines 4 through 7): $ 8) Less (Credit): ($ ) Fee for filing Statement (fee due whether or not premiums were written for the quarter): Total Amount of Check: $ ________________________________ ________________________________ (Signature of Authorized Representative) (Print Name of Authorized Representative) _________________________ _______________________________ Date Signed Title of Authorized Representative 1. Make check payable to: Government of the U.S. Virgin Islands 2. Payment made must be for each individual company. (Checks for groups will not be accepted.) 3. To avoid penalty, remit or have 1st, 2nd, 3rd, & 4th quarter payment postmarked no later than the 1st of May, August, November, of the current year and February of the next year, respectively. *22 V.I. Code Section 603 (b) was ammended by Act 6287 to exempt annuities from payment of premium tax. CREDIT MUST BE REQUESTED OF THE DIVISION BEFORE IT IS APPLIED Office of The Lt. Governor: Division of Banking, Insurance and Financial Regulation: Kongens Gade #5049: St. Thomas, U.S. Virgin Islands: 00802-6487: Phone (340) 774-7166 :Facsimile (340) 774-9458