Form Lgt 140 – Fill Out and Use This PDF

Commonwealth of Kentucky, Office of Insurance

CITY, COUNTY, OR URBAN COUNTY GOVERNMENT INSURANCE PREMIUM TAX

ANNUAL RECONCILIATION

FILER INFORMATION

Complete either the information for a direct writer or surplus lines broker depending upon the filer type.

		Insurance Company (Direct Writer):					Surplus Lines Broker:
		Name							(Name)
									(Title)
		Address							(Address)
		City, State, ZIP							(Phone)
		Phone							(Email Address)
		Email Address						Account Number ______________
		Employer Identification Number
								Tax Year Ending ______________
		NAIC Number
		Name of City, County, or Urban County Government:			LOUISVILLE METRO, KENTUCKY
					SECTION I
			Established	Premiums	Tax Payable		Collection Fee	Collected from	Additional Tax Due or
			Tax Rate %	Collected	[(1) x (2)]		Retained	Policyholders	(Overpayment)
			(1)	(2)	(3)		(4)	(5)	(6)
		1ST QUARTER

Casualty

Fire & Allied Perils

Inland Marine

Life

Motor Vehicle

All Other Risks

Health (1)

(1) Note > Include only premiums received in the Metro Louisville Urban Service District (formerly the City of Louisville) on the Health Line.

Credits (Form LGT 142)

Total

2ND QUARTER

Casualty

Fire & Allied Perils

Inland Marine

Life

Motor Vehicle

All Other Risks

Health (1)

(1) Note > Include only premiums received in the Metro Louisville Urban Service District (formerly the City of Louisville) on the Health Line.

Credits (Form LGT 142)

Total

FORM LGT 140

MAILING ADDRESS: LOUISVILLE METRO REVENUE COMMISSION

P.O. BOX 37740  LOUISVILLE, KENTUCKY 40233-7740

Telephone: (502) 574-4860  www.metrorevenue.org  Fax: (502) 574-4818  taxhelp@metrorevenue.org  TDD: (502) 574-4811

SECTION I (Continued)

		Established	Premiums	Tax Payable	Collection Fee	Collected from	Additional Tax Due or
		Tax Rate %	Collected	[(1) x (2)]	Retained	Policyholders	(Overpayment)
		(1)	(2)	(3)	(4)	(5)	(6)
	3RD QUARTER
	Casualty
	Fire & Allied Perils
	Inland Marine
	Life
	Motor Vehicle
	All Other Risks
	Health (1)

(1) Note > Include only premiums received in the Metro Louisville Urban Service District (formerly the City of Louisville) on the Health Line.

Credits (Form LGT 142)

Total

4TH QUARTER

Casualty

Fire & Allied Perils

Inland Marine

Life

Motor Vehicle

All Other Risks

Health (1)

(1) Note > Include only premiums received in the Metro Louisville Urban Service District (formerly the City of Louisville) on the Health Line.

Credits (Form LGT 142)

Total

ANNUAL TOTALS

Casualty

Fire & Allied Perils

Inland Marine

Life

Motor Vehicle

All Other Risks

Health (1)

(1) Note > Include only premiums received in the Metro Louisville Urban Service District (formerly the City of Louisville) on the Health Line of Insurance.

Credits (Form LGT 142)

Total

	SECTION II - COMPUTATION OF ADDITIONAL PAYMENT DUE
	(Do not complete if no additional tax is due for any quarter.)
Quarter	Tax Balance Due	Annual Interest Rate	Interest Due	Total Tax and	Date Tax
				Interest Due	Was Paid
1st
2nd
3rd
4th
Total

INSTRUCTIONS FOR FILING LOCAL GOVERNMENT INSURANCE

PREMIUM TAX ANNUAL RECONCILIATION (FORM LGT 140)

(KRS 91A.080, 806 KAR 2:095, and 2:097)

1.THIS FORM MUST BE FILED ON OR BEFORE MARCH 31ST OF EACH YEAR with the local government to which it applies, and a copy to the Department of Insurance, Local Government Premium Tax Unit, P.O. Box 517, Frankfort, Kentucky, 40602, accompanied by a $5.00 fee per insurance company/surplus lines broker payable to the Kentucky State Treasurer. Where there are no premiums collected within any of the taxing authorities, see #6 below. Inquiries regarding the preparation of the annual reconciliation should be directed to the address above or by calling 502-564-1649. You can also contact the Louisville Metro Revenue Commission at (502) 574-4860. Our office is located at 617 West Jefferson Street, Louisville, Kentucky 40202.

2.EACH INSURANCE COMPANY/SURPLUS LINES BROKER MUST FILE. GROUP FILINGS ARE NOT ACCEPTABLE. Always give the employer identification number assigned by the IRS and other required information, including the telephone number of the person preparing the return. Please do not staple the filings.

3.Each tax return for each local government must bear the certification (signature of preparer and date prepared) as shown on the return.

4.Any license fee or tax not paid on or before the due date shall bear interest at the tax interest rate as defined in KRS 131.010(6) from the date due until paid. Such interest is payable to the local governments.

5.The tax rates may change effective July 1. Be certain to obtain the correct tax percentage from the Kentucky Department of Insurance.

6.If the insurance company/surplus lines broker has collected no premiums within any taxing authority for the kinds of insurance subject to this tax, the insurance company/surplus lines broker shall notify the Department of Insurance by completing Form LGT-140 and state the reason that no Kentucky Local Government Premium Taxes were due. This report shall contain the signature of the company official or other person responsible for preparing the report and be accompanied by a fee of $5.00 per insurance company/surplus lines broker. An insurance company/surplus lines broker shall not file Form LGT-140 with local governments where the tax liability is “NONE”.

7.Reports that are not legible will not be accepted.

8.Annual reconciliations must be filed by tax year. We cannot approve more than one form per company for this local government. When errors are found, a new annual reconciliation must be completed in its entirety and amended to include corrections. Submit the amended form to this local government along with additional money due, if applicable, and a copy of the form to the Department of Insurance.

9.SPECIAL INSTRUCTIONS RELATED TO SURPLUS LINES BROKERS

Annual reconciliations shall be filed with the Department of Insurance and the applicable local government by the surplus lines broker. Each return submitted to the local governments shall include a listing of the insurance companies that supplied the coverage for which the premiums and taxes are being reported. This information shall be listed in Section III of Form LGT-140. Please note that surplus lines brokers are not required to submit a separate Form LGT-140 to each local government for each insurance company through which insurance business was exported.

10.PROPER COMPLETION OF THE ANNUAL RECONCILIATION

The Department of Insurance has automated the Kentucky Local Government Premium Tax information.

A.SECTION I

QUARTERLY INFORMATION:

Column 1: Use the tax rate in effect for each quarter for each line of coverage. If premiums were returned at a different rate, they must be listed as a separate line item within that line of coverage.

Column 2: Include all premiums received at an insurance company’s home, administrative, or regional offices during a calendar quarter for the lines of coverage subject to LGPT. This column is for the reporting of premiums only. Do not add the amount of taxes collected or paid to the amount reported in this column.

Column 3: This is the amount actually due the local government for each quarter (check schedule for minimum taxes or flat fees). In this column, always indicate the amount of tax that should have been paid even when filing amended reconciliations.

Column 4: The collection fee shall be 15% of the tax or 2% of the premium, whichever is less. (The collection fee is not to be deducted from the tax payable.)

Column 5: When the tax payable (the amount in Column 3) is assessed upon the policyholder, Column 5 is the total of Columns 2 and 3. When the tax and collection fee are assessed upon the policyholder, Column 5 is the total of Columns 2, 3 and 4. If the tax and collection fee are paid solely by the insurance company/surplus lines broker, Column 5 will equal Column 2.

Column 6: This is used when there was an error reported in Column 3 on the quarterly filings (Form LGT-141) to the local government. When any additional tax is due the local government, the amount should be shown in Column 6 and also in Section II for computation of interest due. Any overpayment should be shown in Column 6 and taken in subsequent quarters.

Credits (Form LGT-142): In the columns for the line listed “Credits (Form LGT 142), please fill out for each quarter and compute the total in the “Annual Totals” section.

ANNUAL TOTALS: Total annual figures for premiums received, tax payable, and interest paid are necessary.

B. SECTION II

This section must be completed for all taxes that were not paid. Be certain to give totals for “Interest Due” and “Total Tax and Interest Due,” along with “Date Tax Was Paid.” Interest is computed from the date the tax was due (30 days after the end of each calendar quarter) until the date the tax is paid at the interest rate prescribed by the Kentucky Revenue Cabinet. The Kentucky Department of Revenue has set the annual interest rate for the 2010 tax year at 3%.

C. SECTION III

Surplus lines brokers filing LGT-140 in accordance with KRS 304.10 shall complete Section III. Each return submitted to the local governments by surplus lines brokers shall include a listing of the insurance companies that supplied the coverage for which the premiums and taxes are being reported. Please note that surplus lines brokers are not required to submit a separate Form LGT-140 to each local government for each insurance company through which insurance business was exported.

D. SECTION IV

Filings will not be approved without the proper certificate (signature of preparer and date prepared).