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Fillable Independently Procured Surplus Lines Premium Tax Statement , Form - hawaii

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ST AT E O F HAW AII INSURANCE DIVISION DEPARTMENT OF COMMERCE & CONSUMER AFFAIRS 335 MERCHANT ST., 2ND FLOOR HONOLULU, HAWAII 96813 INDEPENDENTLY PROCURED SURPLUS LINES DURING THE PERIOD JULY 1, 2011 ­ JULY 20, 2011 REPORTING RISKS LOCATED IN HAWAII ONLY PREMIUM TAX STATEMENT General Information (Print or Type) Name of Insurance Company: Mailing Address: City/State/Zip: Name of Agency: (if applicable) Mailing...
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