West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-20 - Surplus Lines Insurance › Appendix A

Current through Register Vol. XLI, No. 28, July 12, 2024
NONADMITTED INSURANCE MULTI-STATE AGREEMENT
				  (NIMA)
WHEREAS
, the Nonadmitted and Reinsurance Reform Act
				  of 2010 ("NRRA"), which was incorporated into the Dodd-Frank Wall Street Reform and
				  Consumer Protection Act, provides that only an insured's "Home State" may require a
				  premium tax payment for Nonadmitted Insurance; and
WHEREAS,
the NRRA authorizes States to enter into a
				  compact or otherwise establish procedures to allocate among the States the
				  Nonadmitted Insurance premium taxes;
NOW, THEREFORE
, in consideration of the foregoing,
				  the Participating States that are signatories hereto, do freely and voluntarily
				  enter into this Agreement under the following terms and conditions:
PART I
Purpose
The purposes of this Agreement, through means of joint and
				  cooperative action among the Participating States, are to:
1. Facilitate the payment and allocation of premium taxes on
				  Nonadmitted Insurance for Multi-State Risks among the Participating States in
				  accordance with the premium tax allocation method and formula contained in the
				  Annexes attached to this Agreement and based on the rates established by each
				  Participating State.
2. Require nationwide uniform requirements, forms and procedures
				  that facilitate the reporting, payment, collection and allocation of premium taxes
				  for Nonadmitted Insurance for Multi-State Risks as contemplated by the NRRA.
3. Coordinate reporting of premium taxes and transaction data on
				  Multi-State Risks among Participating States.
4. Establish a Clearinghouse to facilitate the receipt and
				  distribution of premium taxes and transaction data related to Nonadmitted Insurance
				  of Multi-State Risks.
PART II
Definitions
5. For purposes of this Agreement, the following definitions shall
				  apply:
a. "
Agreement
" means this Nonadmitted Insurance
				  Multi-State Agreement (NIMA), entered into by the Participating States pursuant to
				  Section 521(b)(1) of the NRRA.
b. "
Admitted Insurer
" means, with respect to a State,
				  an insurer that is licensed to transact the business of insurance in such
				  State.
c. "
Clearinghouse
" means the entity established
				  pursuant to this Agreement to facilitate the receipt and distribution of premium
				  taxes and transaction data related to Nonadmitted Insurance.
d. "
Home State
" means,
(1) In General.-Except as provided in paragraphs (2) through (5),
				  the term ''Home State'' means, with respect to an insured-
(A) the State in which an insured maintains its principal place of
				  business or, in the case of an individual, the individual's principal residence;
				  or
(B) if 100 percent of the insured risk is located out of the State
				  referred to in subparagraph (A), the State to which the greatest percentage of the
				  insured's taxable premium for that insurance contract is allocated.
(2) "Principal place of business" means, with respect to
				  determining the Home State of the insured, (a) the State where the insured maintains
				  its headquarters and where the insured's high-level officers direct, control and
				  coordinate the business activities; or (b) if the insured's high-level officers
				  direct, control and coordinate the business activities in more than one State, the
				  State in which the greatest percentage of the insured's taxable premium for that
				  insurance contract is allocated; or (c) if the insured maintains its headquarters or
				  the insured's high-level officers direct, control and coordinate the business
				  activities outside any State, the State to which the greatest percentage of the
				  insured's taxable premium for that insurance contract is allocated.
(3) "Principal residence" means, with respect to determining the
				  Home State of the insured, (a) the State where the insured resides for the greatest
				  number of days during a calendar year; or (b) if the insured's principal residence
				  is located outside any State, the State to which the greatest percentage of the
				  insured's taxable premium for that insurance contract is allocated.
(4) Affiliated Groups.-If more than one insured from an affiliated
				  group are named insureds on a single Nonadmitted Insurance contract, the term ''Home
				  State'' means the Home State, as determined pursuant to subparagraph (A) of
				  paragraph (1) of this subsection, of the member of the affiliated group that has the
				  largest percentage of premium attributed to it under such insurance contract.
(5) Group Insurance. When the group policyholder pays 100% of the
				  premium from its own funds, the term "Home State" means the Home State, as
				  determined pursuant to subparagraph (A) of paragraph (1) of this subsection, of the
				  group policyholder. When the group policyholder does not pay 100% of the premium
				  from its own funds, the term "Home State" means the Home State, as determined
				  pursuant to subparagraph (A) of paragraph (1) of this subsection, of the group
				  member.
e. "
Independently Procured Insurance
" means insurance
				  procured by an insured directly from a Nonadmitted Insurer as permitted by the laws
				  of the Home State.
f. "
Licensed
" means, with respect to an insurer,
				  authorization to transact the business of insurance by a license, certificate of
				  authority, charter, or otherwise.
g. "
Multi-State Risk
" means a risk covered by a
				  Nonadmitted Insurer with insured exposures in more than one State.
h. "
Nonadmitted Insurance
" means any Property and
				  Casualty Insurance permitted in a State to be placed directly or through a Surplus
				  Lines Licensee with a Nonadmitted Insurer eligible to accept such insurance. For
				  purposes of this Agreement, Nonadmitted Insurance includes Independently Procured
				  Insurance and Surplus Lines Insurance.
i. "
Nonadmitted Insurer
" means, with respect to a
				  State, an insurer not licensed to engage in the business of insurance in such State,
				  but shall not include a risk retention group, as that term is defined in section
				  (2)(a)(4) of the Liability Risk Retention Act of 1986 (
				  15 U.S.C.
				  3901(a)(4) ).
j. "
Non-Participating State
" means any State that has
				  not executed this Agreement.
k. "
Participating State
" means any State that has
				  executed this Agreement and that has not withdrawn or defaulted pursuant to Part
				  VII.
l. "
Property and Casualty Insurance
" means any kind
				  of insurance on property, fidelity and surety insurance, or liability insurance, but
				  does not mean title insurance, workers' compensation insurance, or any insurance on
				  the life of a person, including life insurance, annuities, accident and health
				  insurance, or disability insurance.
m. "
Single-State Risk
" means a risk with insured
				  exposures in only one State.
n. "
Surplus Lines Insurance
" means insurance procured
				  by a Surplus Lines Licensee from a Surplus Lines Insurer as permitted under the law
				  of the Home State; for purposes of this Agreement, "Surplus Lines" shall also mean
				  excess line as may be defined by applicable State law.
o. "
Surplus Lines Insurer
" means a Nonadmitted
				  Insurer permitted under the law of the Home State to accept business from a Surplus
				  Lines Licensee.
p. "
Surplus Lines Licensee
" means an individual, firm
				  or corporation that is licensed in a State to sell, solicit or negotiate insurance,
				  including the agent of record on a Nonadmitted Insurance policy, on properties,
				  risks or exposures located or to be performed in a State with Nonadmitted
				  Insurers.
6. In this Agreement, unless otherwise specified, words or
				  expressions used in this Agreement have the same meaning as in the Nonadmitted and
				  Reinsurance Reform Act of 2010.
7. The following are the Annexes that are attached to, and that
				  form an integral part of, this Agreement:
Annex A
- Nonadmitted
				  Insurance Premium Tax Allocation Schedule;
Annex B
- Allocation
				  Formula; and
Exhibit 1
- Information Required to be Submitted by the
				  Broker or Insured via the Clearinghouse Web Portal.
PART III
Implementation
8. The Participating State, as signatory herein, represents that
				  it has the legal authority necessary to enter into this Agreement for the purposes
				  stated in the Agreement, including the allocation among the other Participating
				  States of applicable Nonadmitted Insurance premium taxes and the use of the
				  designated Clearinghouse for the facilitation of the payment and distribution of
				  such premium taxes.
9. Pursuant to the terms of this Agreement, each Participating
				  State agrees to:
a. implement nationwide uniform requirements, forms and procedures
				  that facilitate the reporting, payment, collection and allocation of premium taxes
				  for Nonadmitted Insurance for Multi-State Risks;
b. allocate among the applicable Participating States the
				  Nonadmitted Insurance premium taxes required by an insured's Home State as described
				  herein;
c. work collaboratively and in a timely manner towards the
				  imposition of NRRA's Nonadmitted Insurance premium tax reforms by July 21, 2011;
				  and
d. establish and utilize a Clearinghouse to facilitate the
				  receipt, allocation, and distribution of the payment of Nonadmitted Insurance
				  premium taxes to the Participating States.
PART IV
Collection and Allocation Procedures
10. The Clearinghouse will operate pursuant to a plan of
				  operation, to be agreed upon by two-thirds of the Participating States, to ensure
				  that the Clearinghouse and its computer software system are capable of meeting the
				  requirements of this Agreement.
11. Each Participating State agrees to use the Clearinghouse for
				  all Multi-State Risks for which that state is the Home State. Except as otherwise
				  provided, each Participating State agrees to require Surplus Lines Licensees and
				  insureds who independently procure insurance to utilize the Clearinghouse for the
				  reporting and payment of Nonadmitted Insurance premium taxes for all Multi-State
				  Risks for which that state is the Home State. This Agreement shall not require a
				  State to treat any Property and Casualty Insurance as Nonadmitted Insurance where
				  the laws of the State do not provide such treatment. Further, each Participating
				  State may, at its discretion, agree to use the Clearinghouse for any Single-State
				  Risks or non-Property and Casualty Insurance risks for which that state is the Home
				  State.
12. Each Participating State agrees to contract with the
				  Clearinghouse to provide the services that are the subject of this Agreement. There
				  shall be no material variations in the terms of each Participating State's contract
				  with the Clearinghouse and each such contract shall include, but not be limited to,
				  terms prohibiting the Clearinghouse from lobbying, accepting gifts or donations,
				  political activity of any kind, or conflicts of interest, and shall include terms
				  requiring confidentiality of information received by or provided to the
				  Clearinghouse.
13. Each Participating State agrees to require the payment of
				  taxes, fees and assessments when the Participating State is the Home State as
				  follows: (a) as determined by the Home State on the portion of the premium allocated
				  to the Home State based on Annex A and Annex B; (b) specified by each Participating
				  State on the portion of the premium allocated to that State based on Annex A and
				  Annex B; and (c) determined by the Home State on any portion of the premium not
				  allocated under subsections (a) and (b) of this section. Each Participating State
				  agrees to establish one tax rate, encompassing any applicable taxes, fees and
				  assessments, that applies to Nonadmitted Insurance; provided, however, that nothing
				  shall require a Participating State to impose a tax on any kind of insurance for
				  which the State presently does not have an obligation to tax or has allowed an
				  exemption; and further provided that, where a Home State utilizes a surplus lines
				  stamping office, the stamping office may, in accordance with the laws of that State,
				  impose stamping fees in addition to the tax.
14. Each Participating State shall give notice to the
				  Clearinghouse of any changes to its statewide Nonadmitted Insurance premium tax rate
				  and any statewide assessments at least 90 days prior to the effective date of such
				  changes. The Clearinghouse will send notice of any changes to all of the
				  Participating States via electronic mail to the designated contact of each
				  Participating State.
15. Each Participating State agrees to authorize the
				  Clearinghouse, when the Participating State is the Home State, to collect a
				  reasonable fee, to be established by contract between the Participating State and
				  the Clearinghouse, payable by the insured directly or through a Surplus Lines
				  Licensee on each transaction processed through the Clearinghouse to cover the cost
				  of the operations and activities of the Clearinghouse. If the Home State has a
				  stamping office, this fee shall be in addition to the service fee that is received
				  by the stamping office.
16. No Participating State, other than the Home State, may require
				  a Surplus Lines Licensee to submit data, reports or insurance documentation to a
				  stamping office of that State. A Home State with a stamping office may require the
				  initial submission of transaction data, premium taxes and fees with the stamping
				  office of that State provided the State agrees by contract with the Clearinghouse to
				  forward relevant transaction data, premium taxes and fees to the Clearinghouse for
				  distribution to other Participating States.
17. Except as otherwise provided, each Participating State agrees
				  to require, by statute or rule, for those policies of Nonadmitted Insurance where
				  that State is the Home State and for which the payment of Nonadmitted Insurance
				  premium taxes is due, that the Surplus Lines Licensee or insured who independently
				  procures insurance shall forward such payments and related information based on
				  Annex A and Annex B to the Clearinghouse for deposit in the Clearinghouse account.
				  Each Participating State agrees to require that the payment of Nonadmitted Insurance
				  premium taxes will be accompanied by transaction data consistent with Exhibit 1.
				  After the Clearinghouse has collected and reconciled the payments, the appropriate
				  amount will be deposited into each Participating State's depository account at the
				  banking institution selected by the Participating State. With respect to the
				  depository accounts of the Participating States, the Clearinghouse shall only have
				  the authority to transfer premium taxes collected and on deposit in the
				  Clearinghouse account into the depository account of the Participating
				  States.
18. For those policies of Nonadmitted Insurance where transaction
				  data consistent with Exhibit 1 is submitted prior to the payment of Nonadmitted
				  Insurance premium taxes, each Participating State agrees that the accounting of
				  taxes due will be tracked by the Clearinghouse, and the payment thereof will be
				  handled by the Clearinghouse. Each Participating State agrees to require the Surplus
				  Lines Licensee or insured who independently procures insurance, as applicable, to
				  submit information based on Annex A and Annex B. The Clearinghouse will assess the
				  allocated premium based upon each Participating State's statewide Nonadmitted
				  Insurance tax rate and statewide assessments for each Participating State with
				  exposure. At the end of the reporting period, the Clearinghouse will allocate the
				  amount collected on behalf of the Home State to all other Participating States and
				  net the amounts owed to or from each of the States. The netting of taxes will be
				  based on the actual amount collected.
19. The Clearinghouse will report to the Participating States,
				  Surplus Lines Licensees and insureds who independently procure insurance, within 15
				  days of the quarterly premium tax filing and payment dates set forth in section 20
				  of this Part, all premium taxes owed to each of the Participating States for the
				  preceding quarter, the dates upon which payment of such premium taxes are due, and
				  the method through which they were paid to the Clearinghouse.
20. Each Participating State agrees that, when it is the Home
				  State, it shall require tax filings and payments quarterly utilizing the following
				  dates only: February 15 for the quarter ending the preceding December 31, May 15 for
				  the quarter ending the preceding March 31, August 15 for the quarter ending the
				  preceding June 30, and November 15 for the quarter ending the preceding September
				  30.
21. The Home State agrees to enforce, if necessary and to the
				  extent allowed by the laws of the Home State, any of the following: unpaid tax;
				  interest due; and applicable penalties. The Home State will follow the calculation
				  of these amounts and the methods of collection governed by the laws of the Home
				  State and the plan of operation adopted pursuant to this Agreement.
PART V
Dispute Resolution
22. Each Participating State agrees to exercise best efforts to
				  reach consensus in respect to disputed issues arising on matters governed by this
				  Agreement.
23. If a dispute arises out of or relates to this Agreement, or
				  the breach thereof, and if the dispute cannot be settled through negotiation, the
				  affected Participating States agree first to try in good faith to settle the dispute
				  by mediation administered by the American Arbitration Association under its
				  Commercial Mediation Procedures before resorting to arbitration, litigation, or some
				  other dispute resolution procedure. A dispute involving one or more Participating
				  States or the Clearinghouse is a dispute arising out of or relating to this
				  Agreement for purposes of this Part.
PART VI
Participating States, Effective Date and
				  Amendment
24. Any State is eligible to become a Participating State. This
				  Agreement shall become effective and binding as of the first day after the
				  conclusion of the calendar quarter in which the Agreement is executed by the duly
				  authorized representative of at least two (2) Participating States. Thereafter, it
				  shall become effective and binding as to any other Participating State as of the
				  first day after the conclusion of the calendar quarter in which such State executes
				  this Agreement.
25. Amendments may be proposed by any of the Participating States
				  under this Agreement. The amendment shall become effective after two-thirds of the
				  Participating States agree in writing to accept the amendment.
PART VII
Withdrawal, Default and Dissolution
26. Withdrawal
a. Once effective, this Agreement shall continue in force and
				  remain binding upon each and every Participating State, provided that a
				  Participating State may withdraw from the Agreement ("Withdrawing State") by
				  providing 60 days' written notice to the Clearinghouse, which shall provide advance
				  written notice to all Participating States and facilitate public notice of the
				  State's withdrawal from the Agreement.
b. The Withdrawing State is responsible for all obligations,
				  duties and liabilities incurred through the effective date of withdrawal, including
				  any obligations, the performance of which extend beyond the effective date of
				  withdrawal.
27. Default
a. If any Participating State has at any time defaulted
				  ("Defaulting State") in the performance of any of its obligations or
				  responsibilities under this Agreement, the Defaulting State shall be suspended from
				  the effective date of default. The grounds for default include, but are not limited
				  to, failure of a Participating State to perform its obligations or responsibilities
				  as required by this Agreement.
b. Reinstatement following termination of any Participating State
				  requires renewed execution of the Agreement.
28. Dissolution of Agreement
a. The Agreement dissolves effective upon the date of the
				  withdrawal or default of the Participating State that reduces membership in the
				  Agreement to one Participating State.
b. Upon the dissolution of this Agreement, the Agreement becomes
				  null and void and shall be of no further force or effect.
PART VIII
Severability and Construction
29. The provisions of this Agreement shall be severable and if any
				  phrase, clause, sentence or provision is deemed unenforceable, the remaining
				  provisions of this Agreement shall be enforceable.
30. The provisions of this Agreement shall be liberally construed
				  to effectuate its purposes.
31. Throughout this Agreement, the use of the singular shall
				  include the plural and vice-versa. The headings and captions of parts, sections,
				  subsections, paragraphs and sub-paragraphs used in this Agreement are for
				  convenience only and shall be ignored in construing the substantive provisions of
				  this Agreement.
PART IX
Binding Effect of Agreement and Other Laws
32. The terms of this Agreement, and the procedures to be
				  established as amendments to this Agreement, are binding upon the Participating
				  States, except as otherwise may be provided herein.
33. Each Participating State agrees to abide by the applicable
				  laws, regulations, and statutes concerning confidentiality and nondisclosure of
				  information to the extent required or allowed by law. This Agreement neither
				  abrogates nor supersedes applicable Participating State laws respecting
				  confidentiality, trade secrets and proprietary information.
PART X
Miscellaneous
34. This Agreement may be executed in any number of counterparts,
				  each of which will constitute an original and all of which taken together will
				  constitute one and the same instrument. Counterparts may be executed either by hard
				  copy or electronically, or by facsimile, and the Participating States shall accept
				  any signatures received by electronic mail or facsimile as original signatures of
				  the Participating State. The Participating State will promptly forward to the other
				  Participating States and the Clearinghouse a signed copy of this Agreement.
35. By entering into this Agreement, a Participating State is not
				  deemed to surrender or abandon any of the powers, rights, privileges or authorities
				  vested in it under its State constitution, statutes, acts, or otherwise, or to
				  impair any of such powers, rights, privileges or authorities.
36. This Agreement, including all Annexes and the Exhibit
				  attached, constitutes the entire agreement between the Participating States with
				  respect to the subject matter of this Agreement and supersedes all prior agreements
				  and understandings between the Participating States with respect to that subject
				  matter.
37. After execution of this Agreement, each Participating State
				  will do, or cause to be done, all acts as the other Participating States may
				  reasonably require from time to time for the purpose of giving effect to this
				  Agreement and each Participating State will use reasonable efforts, and take all
				  steps as may be reasonably within that Participating State's power, to implement to
				  its full extent the provisions of this Agreement.
_____________________________________
[SIGNATURE OF STATE OFFICIAL]
ANNEX A
Nonadmitted Insurance Premium Tax Allocation
				  Schedule
This Annex to the Agreement sets forth the provisions governing
				  the method of tax allocation for Multi-State Risks, as specified in Part III. If the
				  allocation schedule does not identify a classification appropriate to the property
				  or risk being insured, then the Surplus Lines Licensee, or an insured who
				  independently procures insurance, consistently shall use an alternative method of
				  equitable allocation across similar types of insurance policies and contracts, and
				  shall maintain for at least five years, documented evidence of the bases and other
				  criteria used by the Surplus Lines Licensee or insured who independently procures
				  insurance in order to substantiate the method.
EXPOSURE ALLOCATION METHODOLOGY
class=Section2
MAJOR COVERAGE
COVERAGE TYPE
INCLUDING
*ALLOCATION BASIS BY STATE
PROPERTY
ALL PROPERTY UNLESS MORE SPECIFICALLY DESCRIBED ELSEWHERE
						  INCLUDES BOTH REAL AND PERSONAL PROPERTY, GLASS, CROP, ANIMALS, RESIDUAL VALUE
ALL RISK INCLUDING LEAKAGE OF SPRINKLERS, EXPLOSION, RIOT
						  & CIVIL COMMOTION, EARTHQUAKE, BLANKET FORM, WATER DAMAGE, BUSINESS
						  INTERRUPTION, TIME ELEMENT OR SIMILAR TIME VALUE COVERAGE, FIRE AND EXCESS OF LOSS
TIV (TIV= PD + BI) TOTAL INSURED VALUE = PHYSICAL DAMAGE +
						  BUSINESS INTERRUPTION
AVIATION
PHYSICAL DAMAGE, ALL OTHERS
TIV
BOILER & MACHINERY
DIRECT, CONSEQUENTIAL, ENGINE & MACHINERY, ALL OTHERS
TIV
INLAND MARINE
FINE ARTS DEALERS, JEWELERS BLOCK, FURRIERS BLOCK, BUSINESS
						  & PERSONAL FLOATER, BUILDERS RISK, ALL OTHER NON APPEARANCE & ABANDONMENT
TIV
INLAND MARINE
MOTOR TRUCK CARGO
GARAGE LOCATION
MOTOR VEHICLE PHYSICAL DAMAGE
TIV OF MOTOR VEHICLES PRINCIPALLY GARAGED OR PRINCIPALLY USED
						  IN STATES
CASUALTY
GENERAL LIABILITY / UMBRELLA / EXCESS LIABILITY
MANUFACTURERS AND CONTRACTORS
PAYROLL IN STATE
PREMISES OPERATIONS
SQUARE FOOTAGE OF PREMISES IN STATE
OWNERS AND CONTRACTORS PROTECTIVE
COST OF CONTRACT IN STATE
PRODUCTS
SALES IN STATE
COMPLETED OPERATIONS
RECEIPTS IN STATE
CHILD CARE
NUMBER OF CHILDREN IN STATE
CONTRACTUAL
IF "STAND ALONE" POLICY, VALUE OF SALES IN STATE
RECREATIONAL
AMOUNT OF GATE RECEIPTS IN STATE
SPECIAL EVENTS
NUMBER OF EVENTS IN STATE
PROFESSIONAL LIABILITY
NUMBER OF INSUREDS IN STATE
ERRORS & OMISSIONS (E&O) / PROFESSIONAL LIABILITY
REVENUES (RECEIPTS) OR NUMBER OF PROFESSIONALS BY STATE
MEDICAL MALPRACTICE
INCLUDES MEDICAL MALPRACTICE FOR INDIVIDUAL HEALTHCARE
						  PROVIDERS OR FACILITIES, I.E. HOSPITALS, NURSING HOMES, PSYCHIATRIC CENTERS
REVENUES (RECEIPTS), NUMBER OF PROFESSIONALS OR BED COUNT BY
						  STATE
CASUALTY (CONT'D)
EMPLOYMENT PRACTICES LIABILITY (EPLI)
EPLI FOR ALL INDUSTRIES
HEADCOUNT BY STATE
MUNICIPALITIES, PUBLIC AUTHORITIES AND OTHER POLITICAL
						  SUBDIVISIONS
NUMBER OF MUNICIPALITIES, ETC.
ENVIRONMENTAL IMPAIRMENT
NUMBER OF UNITS OF EXPOSURE
ASBESTOS ABATEMENT
PAYROLL
EMPLOYEE/MEMBER BENEFIT PROGRAM
NUMBER OF EMPLOYEES/MEMBERS
MOTOR VEHICLE
AUTOMOBILE LIABILITY, EXCESS AUTOMOBILE LIABILITY
NUMBER OF MOTOR VEHICLES PRINCIPALLY GARAGED OR PRINCIPALLY
						  USED IN STATES
RAILROAD PROTECTIVE
MILES OF TRACK IN STATE
MARINE
VESSELS
PRINCIPAL BERTHING LOCATION
ALL OTHER PROPERTY
TIV
AVIATION
AIRCRAFT
NON-OWNED AIRCRAFT, AIRCRAFT LIABILITY
HANGAR LOCATION
FINANCIAL RISK
DIRECTORS AND OFFICERS LIABILITY
GENERAL PARTNERSHIP LIABILITY
REVENUE GENERATED IN STATE
SEC LIABILITY
UNAUTHORIZED TRADING
REVENUE GENERATED IN STATE
KIDNAP & RANSOM
EMPLOYEES
EXCESS SIPC
REVENUE GENERATED IN STATE
MORTGAGE IMPAIRMENT
TIV
FINANCIAL RISK (CONT'D)
PATENT INFRINGEMENT
REVENUE GENERATED IN STATE
SECURITIES
MAIL
TIV
MEDIA LIABILITY
TIV
SERVICE CONTRACTS/WARRANTIES
REVENUE GENERATED IN STATE
TAX OPINION GUARANTEE
REVENUE GENERATED IN STATE
INTELLECTUAL PROPERTY
REVENUE GENERATED IN STATE
CRIME
CRIME
BLANKET CRIME, FIDELITY BOND, INDIVIDUAL BOND, EMPLOYEE
						  DISHONESTY, FORGERY, THEFT, ROBBERY, BURGLARY, FRAUD
EMPLOYEE COUNT
ACCIDENT AND HEALTH
ACCIDENT AND HEALTH
DISEASE, ACCIDENTAL INJURY OR DEATH, MEDICAL SURGICAL
						  EXPENSES AND INCOME PAYMENTS
LOCATION OF EMPLOYEES OR CORPORATE HEADQUARTERS
CREDIT
CREDIT
VALUE OF INSURED DEBT IN STATE
FIDELITY & SURETY
PERFORMANCE BONDS
TOTAL BOND VALUE OF CONTRACTS IN STATE
OTHER SURETY BONDS
TOTAL BOND VALUE OF CONTRACTS IN STATE
* U.S. PREMIUM ONLY
ANNEX B
Allocation Formula
For the purposes of this Annex and subject to Parts III, IV, and
				  VII, the Nonadmitted Insurance premium tax revenue for a calendar tax year or for a
				  sub-period of a calendar tax year, as the case may be, is the amount determined by
				  the formula:
Tax Allocation = (Net tax due to each State/net tax due to all
				  States) x Amount collected
Home State Net Taxes = (Taxes collected for the Home State + Taxes
				  due from other Participating States) - Taxes owed to other Participating
				  States
Total Premium Tax to be Collected on Each Multi-State Policy =
				  (Home State's tax rate x Portion of premium allocated to Home State) + (Home State's
				  tax rate x Premium allocated to Non-Participating State if insurer is nonadmitted in
				  that State) + (Participating States' tax rate x Premium allocated to each
				  Participating State if insurer is nonadmitted in that state)
Exhibit 1
Information Required to be Submitted
By the Broker or Insured via the Clearinghouse Web
				  Portal
A. Submission Contact
Name
Address
Phone Number
E-mail address
Independently procured policy? (Y/N)
B. Agency/Brokerage Firm Data
State
License Number
Name
Address
Phone Number
C. Agent/Sublicensee or Individual Licensee
				  Data
State
License Number
Name
Office Address
Mailing Address
Phone Number
E-mail Address
D. Billing Contact
Name
Address
E-mail Address
Phone Number
E. Policy Data
Policy Number/Binder Number if Policy Number is not
				  available
Effective Date
Expiration Date
Insured Name
Home State of Insured
F. Transaction Data
NAIC Insurer Code Number(s)
Insurer Name(s)
Total Policy Premium by Insurer(s)
Coverage Code
Tax Status
Transaction Type (New, Renewal or Endorsement)
Allocation among States:
Allocation Method
Premiums Allocated to Each State