MONTANA COMMISSIONER OF SECURITIES AND INSURANCE
2019 ANNUAL REPORT (Due March 1, 2020)
PURCHASING GROUPS
Purchasing Group Name Montana ID #
Mailing Address City State Zip Code
Purchasing Group Phone Number Purchasing Group Fax Number Purchasing Group E-Mail Address
Purchasing Group Contact Name Purchasing Group FEIN Number
Contact Mailing Address City State Zip Code
Contact Phone Number Contact Fax Number Contact E-Mail Address
PREMIUM REPORT – INFORMATIONAL PURPOSES ONLY
Licensed Montana Gross Direct Premiums
Name of Insurer(s) Providing Coverage to Purchasing Group Insurance Producers Written in Montana
Total Purchasing Groups Number of Members in Montana:
Is the Insurer, identified above responsible for all premium tax that is to be paid to the State of Montana? Yes No
If no, complete the next two items below. NO SURPLUS LINES TAXES ARE TO BE PAID WITH THIS RENEWAL. THE SURPLUS LINES AGENT MUST
FILE SURPLUS LINES TRANSACTION AND FEES PER INSTRUCTIONS AT THE FOLLOWING LINK:
http://csimt.gov/insurance/surplus-lines/
Name of Surplus Lines Agent (if not listed as Licensed MT Insurance Producer) __________________________________________________________
If any premium tax has not been remitted by the Insurer, who is the responsible party for the premium tax? (Either the Purchasing Group or the
Individual Members) Purchasing Group Individual Members
On the lines below, list the name and amount of premium tax owed to the State of Montana by the Purchasing Group or Member(s). (Attach
additional pages if necessary.)
Name Amount of Premium Tax Rate Amount of Tax Owed
2.75%
2.75%
List the names and titles of any changes of the person(s) controlling the group:
The above statement is a true and correct report of premium written and premium taxes paid or owed pertaining to business transacted in Montana.
Name of Officer (Type or Print) Title of Officer (Purchasing Group)
Signature of Officer Date
Return Form by March 1, 2020. Please e-mail your completed survey in pdf format to csiexams@mt.gov. Faxed or printed and mailed forms will be
accepted, although digital submissions are preferred.
State Auditor’s Office - Insurance Examination Division - 840 Helena Avenue - Helena, MT 59601 - Phone (406) 444-4489 - Fax (406) 444-3497
I hereby intend by checking this box to be the equivalent of my signature
