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
