SURPLUS LINES PAYMENT VOUCHER - Maryland
MARYLAND INSURANCE ADMINISTRATION
SURPLUS LINES TAX PAYMENT VOUCHER
|Surplus Lines Broker Name: |Surplus Lines Broker No. |
| | |
|Mailing Address: |
| |
| |
|City: |State: |Zip Code: |
| | | |
|Telephone Number: |Email Address: |
| | |
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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