Send all documentation to:
Check only one:
Insurance Report Annual R
eport (all other business entities)
Third-Party Audit
Name of person requesting exception:
Email: Must be email of person requesting exception or form will be rejected
Holder Name as it appears on online report (Also see
Phone #: Fax#:
City: State: Zip:
Amount of Payment (must be exact)
Is your business capable of remitting payment via ACH Debit using our online portal? Yes No
If “NO”, provide detailed explanation below as to why not.
If “Yes”, please provide detailed explanation below. If additional space is required, please indicate below (“see attached”) and attach additional
documentation. If your company policies prevent ACH Debit, please state that below.
Effective July 1, 2019: A holder that fails to make a payment as required by subsections 11 and 12 of NRS 120A.560 must be assessed by the
administrator a fee for each such payment in an amount equal to the greater of $50 or 2 percent of the amount of the payment. NRS 120A.730 for
If your request is approved, the FEIN/TIN on the holder report must also be provided in your EFT payment instructions when paying by ACH credit or wire
transfer. If paying by check, the FEIN must be disclosed on the check. If the request is incomplete, it will be rejected.
Must complete table below for every report that this payment related to. This is a single use exception.
This form must be submitted/approved prior remitting payment. The deadline to submit to for 2020 Insurance filing is May 26, 2020.
Please provide a detailed explanation.
I declare to the best of my knowledge and belief that the information provided in this document and in any attached documentation is true and correct
and that the individual signing this form is an authorized officer of the entity.
Printed Name
Title of Authorized Officer
For Official Use
Program Officer
Approved Denied
Program Officer Signature
Requests submitted without required documentation are not guaranteed acceptance and/or approval if resubmitted after the 26
day before the report due date.
In no event shall this form be liable for any exception request received after the 26
day before the report due date and will not guarantee requests will be
Holders paying in a manner other than ACH debit without prior written approval from this office, will be subject to a fee.
ACH Debit Payment Exception Form Insurance Reports 2020
You must complete the information below for each report being submitted in conjunction with this payment exception request.
Missing or incomplete information will result in rejection or denial of your request. Information below must match the reports that
are submitted. If changes are made to your reports after approval of this request, please notify
Business Name (As included on Report)
FEIN (mandatory)
match payment amount)
Name of User Uploading Report(s) through Reporting
Email Address of User Uploading Report(s)