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Get KY 74A118 2015

/ Tax Mo. Yr. Account Number Check Here if Amended Return Check Here if Surplus Lines See reverse for information or call the Department of Revenue, (502) 564-4810. Name and Address Report for Month of Mo. / 20 NAIC FEIN 1. Total premiums (including those premiums not subject to surcharge deducted on Lines 2B and 2C), assessments and other charges collected on risk located in Kentucky (exclude munic.

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