Fillable INSURANCE MUNICIPAL LICENSE (City of Savannah, GA)

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INSURANCE MUNICIPAL LICENSE (City of Savannah, GA)

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File type: PDF

U.S.A. forms for City of Savannah, GA

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INSURANCE MUNICIPAL LICENSE
CITY OF SAVANNAH – REVENUE DEPARTMENT
(912) 651-6451
305 FAHM STREET
P O Box 1228
Savannah GA 31402-1228
Account No:
Calendar Year: 2020
Classification: Insurance Agencies/Broker
PIN (if local):
Tax Type: INS
Account Class:
Location(s) (if local):
Application and Full Payment are Due April 30, 2020.
(ALL FIELDS MUST BE COMPLETED)
2. Date Business Closed:
(if final return)
4. Fax #:
5. E-mail
Address:
8. Owner/Corporation
Name:
10. FEIN #:
11. Total License Fees Due
A. Insurer Annual License Fee:
$ 150.00
$ 150.00
Other Fees:
Number of
Locations
Fees
B. License Fees for Additional Business Locations:
X
$ 150.00
= $
C. Additional Business Locations with Certain Risks:
X
$ 52.50
= $
TOTAL AMOUNT DUE (A+B+C)
$
Print Name _____________________________________________________ Title___________________________________________
Signature ______________________________________________________ Date _________________________________________
Ple
ase make all checks payable to the City of Savannah and mail to the address above.
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INSURANCE MUNICIPAL LICENSE (City of Savannah, GA)

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Completed 14 May 2021

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