Direct any questions to: DOI_SLTAX@delaware.gov
STATE OF DELAWARE
DEPARTMENT OF INSURANCE
2019 INDEPENDENT PROCUREMENT PREMIUM TAX
REPORT All statutory references are to Title 18, Delaware
Insurance Code.
Original Report
Amended Report
SELF-PROCURED
SURPLUS LINES
AFFIDAVIT
I hereby verify that the information contained in this report is a true and correct statement of surplus lines insurance directly
procured by me covering risks located in the state of Delaware as described herein.
Sworn to and subscribed before me this date.
Signed this date:
Sign
Here
Printed Name of Insured or Insured’s Officer Signature of Insured or Insured’s Officer
Sign
Here
Affiant’s Title
Signature Notary Public Notary Seal
IF DELAWARE IS THE HOME STATE OF THE INSURED AS DEFINED IN 18 DEL. C. §1904, AND IF ANY PART OF
THE RISK EXPOSURE IS LOCATED WITHIN THIS STATE, THIS REPORT MUST BE COMPLETED FOR ANY
INSURANCE PURCHASED FROM A NONADMITTED INSURER WITHOUT THE INVOLVEMENT OF A SURPLUS
LINES BROKER, AND TAX OF 3% MUST BE PAID TO THE STATE ON THE ENTIRE POLICY PREMIUM PER §1925.
Independent Procurement Statement
I qualify as a “home state insured” as defined in 18 Del. C. §1904, and I have been unable to procure the insurance coverage
described herein from licensed insurers, which are authorized in Delaware to transact the class of insurance involved, and which
accept, in the usual course of business, insurance on risks of the same class as the risk described below; or I was not able to procure
from licensed companies the full amount of insurance needed. Having been unable to secure such coverage, I have resorted to
obtaining coverage with companies not licensed in the State of Delaware and therefore not under the jurisdiction of the Delaware
Insurance Department.
The amount of insurance purchased from the unauthorized insurer(s) is only the excess coverage. Furthermore, this insurance was
not purchased from an unauthorized insurer for the purpose of securing more favorable premium rates or policy terms than would be
accepted by an authorized insurer.
I understand that the unauthorized insurance company is not a member of the Delaware Insurance Guaranty Association and that
Chapter 42 of the Delaware Insurance Code is not applicable to claimants or insureds of this company. This purchase of insurance
was made in compliance with 18 Del. C. §1926, and this report and tax payment is made as required therein.
INSURANCE COMPANY NAME NAIC # (obtain from Insurer) POLICY NUMBER
INSURED POLICYHOLDER NAME AND MAILING ADDRESS
Company Name
Federal EIN:
IMPORTANT
Address
POLICY DETAILS
Effective Date Expiration Date
City/State/Zip to
Contact Person
MM/DD/YYYY Format MM/DD/YYYY Format
Contact Email
TAX PREPARER NAME AND ADDRESS (if different) TYPE OF INSURANCE
Name
Address
DESCRIPTION OF COVERAGE
City/State/Zip
Contact Person
AMOUNT(s)/LIMIT(s) OF INSURANCE
Contact Email
PREMIUM TAX CALCULATION
MAIL PAYMENT AND THIS FORM TO:
Gross Premium:
LESS Return Premium:
Net Taxable Premium:
DE Tax Rate (3% per §§1925(e), 1926): .03
Delaware Insurance Department
Attn: SURPLUS LINES SECTION
1351 West North Street, Suite 101
Dover, DE 19904
Total Premium Tax Due: Pay this amount
Make checks payable to Delaware Insurance Department
In the State of __________________ County of _______________________ on this date, before me, the subscriber, personally appeared the officer
for the insured listed above, who deposes and says that this report and all schedules are true, correct, and complete.
