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ENTER HOLDER INFORMATION
* Required field
Primary Holder Info section header
Primary Holder Information
Please enter the following information:
*
Holder Name
:
*
Holder Tax ID
:
*
Holder ID
:
*
Life Insurance Confirmation
:
*
Contact Name
:
*
Contact Phone Number
:
*
Phone Extension
:
*
Email Address
:
*
Email Address Confirmation
:
Report Info section header
Report Information
Please enter the following information:
*
Are you submitting this report in response to an outreach letter received from the State?
:
Yes
No
*
Reference ID
:
*
Report Type
:
Annual Report
Reciprocal Report
Supplemental Report
Tangible Report
*
Report Year
:
- Select an Option -
2020
2021
2022
2023
2024
*
State
:
- Select an Option -
AA-APO
AE-APO
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AP-APO
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South Carolina
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Texas
U.S. Minor Outlying Islands
Utah
Vermont
Virginia
U.S. Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
*
Total Dollar Amount Remitted
:
*
Funds Remitted Via
:
ACH / Electronic
Other
*
Does this report include records that are subject to the HIPAA Privacy Rule?
:
?
Yes
No
?
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