New York Tax on Premiums Paid or Payable To an Unauthorized Insurer-For Taxable Insurance Contracts with an Effective Date on or after July 21, 2011.See TSB-M-

Tax on Premiums Paid or Payable To an Unauthorized Insurer-For Taxable Insurance Contracts with an Effective Date on or after July 21, 2011.See TSB-M-
Form CT-33-D:8/15:Tax on Premiums Paid or Payable To an Unauthorized Insurer For Taxable Insurance Contracts with an Effective Date on or after July 2
CT-33-D

(8/15)

Amended
return

Department of Taxation and Finance

Tax on Premiums Paid or Payable
To an Unauthorized Insurer

For Taxable Insurance Contracts with an Effective Date on
or after July 21, 2011
Tax Law — Article 33-A

	Employer identification number (EIN) or social security number of insured	 Insurance policy number
	Name of insured		

Calendar quarter and year policy effective /renewed

For Tax Department use only

			
Jan. -  Mar. 	
Apr. - Jun.
(yyyy)
(yyyy)
	Number and street or PO box		
Jul. - Sep.
Oct. -  Dec.
(yyyy)
			
	 (yyyy)
	City	
State	
ZIP code	
Telephone number
					 (  )

If the premiums paid are to an affiliated insurance company, provide the information requested below and mark an X in the box........
Name of affiliated insurance company	

EIN of affiliated insurance company

If premiums paid are an endorsement to the original policy, mark an X in the box	
Type of organization (mark an X in one box)

Effective date of endorsement:		

	

Other:

Corporation	

Partnership	

Individual	

	A.	Pay amount shown on line 8. Make payable to: Commissioner of Taxation and Finance.
		 Include on the payment your identification number, Form CT-33-D, and the calendar quarter
		 for which you are reporting. (See instructions for details.)	

Payment enclosed

A	

Part 1 – Tax computation

	1	 Premiums paid or payable on taxable insurance contracts (see instructions).................................... 	
	2	
Tax rate of 3.6%.................................................................................................................................	
	 3	 Tax due (multiply line 1 by line 2) ......................................................................................................... 	
	4	
Prepayment.......................................................................................................................................	
	5	
Balance (if line 3 is greater than line 4, subtract line 4 from line 3) .............................................................	
	6	
Interest on late payment (see instructions)......................................................................................... 	
	7	
Penalties (see instructions)................................................................................................................. 	
	8	
Total payment due (add lines 5, 6, and 7 and enter here; enter the payment amount on line A above) ..........	
	9	
Overpayment (if line 3 is less than line 4, subtract line 3 from line 4) 	 Credit to next period	
Refund	

1
2	
3
4
5
6
7
8
9

0.036

Part 2 – Insurer information (attach additional sheets if necessary)
	 Name of insurance company
	 Number and street or PO box of insurance company
	 City	

State	

ZIP code

Certification: I certify that this return and any attachments are to the best of my knowledge and belief true, correct, and complete.
Authorized
person
Paid
preparer
use
only

(see instr.)

Printed name of authorized person	

Signature of authorized person	

	 E-mail address of authorized person	

Telephone number	

(		

	 Firm’s name (or yours if self-employed)		
	 Signature of individual preparing this return	

Address	

	 E-mail address of individual preparing this return		

475001150094

Official title

)

Firm’s EIN	

Date
Preparer’s PTIN or SSN

City	
Preparer’s NYTPRIN	

State	
or	

Excl. code	 Date

ZIP code