Del. Admin. Code tit. 18, 2000, 2001, STATE OF DELAWARE-INSURANCE DEPARTMENT, exh. D
INSURANCE DEPARTMENT
STATE OF DELAWARE
1351 WEST NORTH ST., SUITE 101
DOVER, DE 19904
ANNUAL REPORT OF INSURANCE PREMIUM FINANCE COMPANIES FOR THE YEAR ENDED DECEMBER 31, 20
DUE ON OR BEFORE MARCH 1st
NOTE: Where insufficient space is provided to set forth the facts adequately, annex a schedule giving the details.
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READ THE INSTRUCTIONS CAREFULLY BEFORE MAKING UP THIS REPORT
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Schedule A
General
Name of Licensee: __________________ License # ________________________
Address, Street and City: _______________________________________________
State Whether Corporation, Partnership, Association or Individual: ______________
Date Licensee Began Business in Delaware: _________________________________
Business Other Than Insurance Premium Finance Business Conducted in Same Offices:
_________________________________________________________________
Name of Principal Officers at Close of Year Covered by this Report:
President ___________________________
Secretary __________________________
Treasurer ________________________
Owner ____________________________
Partners ___________________________
SCHEDULE B Balance Sheets - As Per Books As at December 31, 20__ and December 31, 20__ | ||
| Assets | End of Present Year | End of Previous Year |
| (7) Loans Receivable | ||
| (8) Cash in Office and in Banks | ||
| (9) Accounts Receivable: | ||
| (A) Parent and/or Affiliated Companies | ||
| (B) Other | ||
| (10) Notes Receivable - Other | ||
| (11) Deferred Charges and Prepaid Expenses | ||
| (12) Fixed Assets (Less Reserve for Depreciation and Amortization | ||
| (13) Other Assets: | ||
| (A) Parent and/or Affiliated Companies | ||
| (B) Other | ||
| (C) All Other Assets | ||
| (14) Total Assets | ||
| LIABILITIES AND CAPITAL | End of Present Year | End of Previous Year |
| (15) Accounts and Notes Payable: | ||
| (A) Banks | ||
| (B) Due to parent Company and/or Affiliated Companies | ||
| (C) Other | ||
| (16) Bonds | ||
| (17) Other Liabilities: | ||
| (A) Accrued Expenses | ||
| (B) All Other Liabilities | ||
| (18) Expenses Reserves: | ||
| (19) Deferred Income: | ||
| (A) Unearned Interest and Fees - Loans Receivable | ||
| (B) All Other Deferred Income | ||
| (20) Branch Office Capital | ||
| (21) Net Worth (If Proprietorship or Partnership) | ||
| (22) Capital Stock (if Corporation) | ||
| (23) Paid in Surplus | ||
| (24) Earned Surplus | ||
| (25) Total Liabilities and Capital | ||
SCHEDULE C Statement of Income and Expense For Period From January 1, 20__ and December 31, 20__ | ||
| GROSS INCOME DERIVED FROM INSURANCE PREMIUM FINANCE BUSINESS End of Present Year End of Previous Year | ||
| (26) Earned Interest Less Refunds | ||
| (27) Earned Fees Less Refunds | ||
| (28) Collection on Loans Previously Charged Off | ||
| (29) All Other Income From Insurance Premium Finance Business (Attach Schedule) | ||
| (30) Total Gross Income Derived from Insurance Premium Finance Business (Items 26 to 29) | ||
| EXPENSES OF CONDUCTING INSURANCE PREMIUM FINANCE BUSINESS | End of Present Year | End of Previous Year |
| (31) Advertising | ||
| (32) Automobile Expense | ||
| (33) Bad Debts, or Reserve for Bad Debts | ||
| (34) Credit and Collection Expense | ||
| (35) Depreciation and Amortization of Fixed Assets | ||
| (36) Donations, Dues and Subscriptions | ||
| (37) Expense, Sundry | ||
| (38) Heat, Light and Water | ||
| (39) Insurance | ||
| (40) Postage and Express | ||
| (41) Legal and Auditing Expense | ||
| (42) Printing, Stationery and Supplies | ||
| (43) Recording Fees - Net | ||
| EXPENSES OF CONDUCTING INSURANCE PREMIUM FINANCE BUSINESS | End of Present Year | End of Previous Year |
| (44) Rent | ||
| (45) Salaries | ||
| (46) Supervision and Administration (When not Allocated to Other Items) | ||
| (47) Taxes | ||
| (A) License Taxes | ||
| (48) Telephone and Telegraph | ||
| (49) Travel | ||
| (50) Other Expenses of Conducting Business Premium Finance Business (Explain): | ||
| (A) | ||
| (B) | ||
| (51) Total Expenses of conducting Business Premium Finance Business (Items 31 to 50) | ||
| (52) Total Net Earnings Derived From Insurance Premium Finance Business for the Period (Before Deducting Interest on Borrowed Funds and Federal and State Taxes on Income) (Item 30 Less Item 51) | ||
SCHEDULE D Reconciliation of Surplus or Net Earnings For Period From _________, 20___ and ___________, 20 ___________ | ||
| SURPLUS, ADDITIONS AND DEDUCTIONS | End of Present Year | End of Previous Year |
| (53) Surplus Balance at End of Previous Period, for Books (Item 24) | ||
| ADDITIONS: | ||
| (54) Total Net Earnings Derived From Insurance Premium Finance Business For The Period (Item 52) | ||
| (55) Other Credits to Surplus for the Period (Attach Explanation) | ||
| (56) Total Additions for the Period (Item 54 to 55) | ||
| DEDUCTIONS: | ||
| (57) Federal and State Taxes on Income | ||
| (58) Interest Paid | ||
| (59) Amortization of Financing Cost | ||
| (60) Dividends Paid During the Period | ||
| (61) Other Charges to Surplus for the Period: | ||
| (A) Transfer of Earnings to net Worth or Home Office Control | ||
| (B) All Other Charges | ||
| (62) Total Deductions for the Period (Item 57 to 61) | ||
| (63) Net Additions to Previous Periods Surplus Balance (Item 56 minus Item 62) | ||
| (64) Surplus Balance at End of Present Period - As Per Books (Item 53 Plus Item 63) (This amount should be the same as Item 24) | ||
AFFIDAVIT County _____________________ State _______________________ I, _______________________ the undersigned, being the __________________________ (Title, if a corporation) of the ___________________________________________ (Name of the insurance premium finance company) swear, (or affirm), that to the best of my knowledge and belief, the statements contained in this report, including the accompanying schedules and statements (if any), are true and that the same is a true and complete statement. By ______________________________________ Title ____________________________________ Subscribed and sworn to before me this _____ day of __________, 20___ _____________________________________ Notary Public Form PF-4 Delaware | ||
Del. Admin. Code tit. 18, 2000, 2001, STATE OF DELAWARE-INSURANCE DEPARTMENT, exh. D