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Get 2011 Ri T 71sp Form

GL 27-3-38.1 SELFPROCUREMENT 2011 INSURED NAME ADDRESS CITY STATE FEDERAL IDENTIFICATION NUMBER/SOCIAL SECURITY NUMBER * CARRIER NAME Broker (if applicable) (Company carrying the risk, not the wholesale broker.) ZIP CODE E-MAIL ADDRESS TYPE OF POLICY COVERAGE EFFECTIVE DATE POLICY # PREMIUM a. b. c. Computation of Tax 1. Gross premium charged - Enter total of amounts in the Premium Column Above ......................................................... 1. 2. SELF PROCUREMENT TAX -.

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