Quarterly  Statement
NAIC Company Code:  ________________                      NAIC Group Code:  ________________
Employer’s ID:  ________________
In Accordance with Section 603 of Chapter 25, Title 22 of the Virgin Islands Code
To the Commissioner of Insurance of the United States Virgin Islands:
The ___________________________________________________________________________
(Name of Company)
of ________________________________,                              State of  _______________________________
(Location of Home Office)
 Date Organized  __________________        Date Admitted to the Virgin Islands   ______________________
 Capital Stock Authorized _________________        Paid in Capital to Date  __________________________
 Lines of Coverage being Written in the Virgin Islands  ___________________________________________
1)
 Losses incurred but not reported:
$
2)
 Amounts actually paid policyholders on Losses:
$
3)
 Amounts paid policyholders as dividends:
$
4)
Amounts of Gross Premiums received or contracted for:
                  Quarter ending:  _________________________
$
5) Amounts paid policyholders as returned Premiums:
($                                  )
6)
Amounts
of
Reinsurance
Premium
Received
from
Unauthorized
Reinsurers (Attach Listing of Named Companies & Amounts):
$
7)
Amounts of Reinsurance Premium Received from Authorized Reinsurers
(Attach Listing of Named Companies & Amounts):
($                                  )
Taxes  Due (5% of the net total of lines 4 through 7):
$
8)
Less (Credit):
($                                  )
Fee for filing Statement (fee due whether or not premiums were
written for the quarter):
Total Amount of Check:
$
________________________________                           ________________________________
        (Signature of Authorized Representative)                                                       (Print Name of Authorized Representative)
_________________________                                             _______________________________
                    Date Signed                                                                                                           Title of Authorized Representative
 1.  Make check payable to:    Government of the U.S. Virgin Islands
 2.  Payment made must be for each individual company.  (Checks for groups will not be accepted.)
 3.  To avoid penalty, remit or have 1st, 2nd, 3rd, & 4th quarter payment postmarked no later than the 1st of May, August,
       November, of the current year and February of the next year, respectively.                                        
*22 V.I. Code Section 603 (b) was ammended by Act 6287 to exempt annuities from payment of premium tax.
                 
 CREDIT MUST BE REQUESTED OF THE DIVISION BEFORE IT IS APPLIED 
 
Office of The Lt. Governor: Division of Banking, Insurance and Financial Regulation: Kongens Gade #5049: St. Thomas, U.S. Virgin Islands: 00802-6487:
 Phone (340) 774-7166 :Facsimile (340) 774-9458