SURPLUS LINES PAYMENT VOUCHER - Maryland



MARYLAND INSURANCE ADMINISTRATION

SURPLUS LINES TAX PAYMENT VOUCHER

|Surplus Lines Broker Name: |Surplus Lines Broker No. |

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|Mailing Address: |

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|City: |State: |Zip Code: |

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|Telephone Number: |Email Address: |

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Filing Date: March 15 _________ Payment Amount: $__________________

September 15 ______

Please submit this voucher with your check made payable to the Maryland Insurance Administration by mail to:

Maryland Insurance Administration

Surplus Lines Premium Tax

200 St. Paul Place, Suite 2700

Baltimore, MD 21202

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