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WYOMING INSURANCE DEPARTMENT
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RISK RETENTION GROUP ANNUAL STATEMENT FILING
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YEAR ENDING DECEMBER 31, 2025
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NAIC Number:FEIN:
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Risk Retention Group Name:
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Address:
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Mailing Address:
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Contact Person:
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Contact Telephone:
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E-Mail Address (Required):
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Group Manager:
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Address:
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Telephone:
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Agent(s):
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TAXES ARE PAID ON A RETALIATORY BASIS
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RetaliatoryState of Wyoming
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Total Direct Premium Written in Wyoming
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Tax Percentage (Retaliatory – Tax rate in State of Domicile)0.75%
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Tax Liability$0.00$0.00
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Enter larger of State of Incorporation or State of Wyoming$0.00
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Add Annual Renewal Fee $200.00
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Total Taxes and Fee$200.00
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Less Prior Year Overpayment
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Less Quarterly Tax Payments
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If Amended, Original Amount Paid
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TOTAL REMITTANCE (OVERPAYMENT)$200.00
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By selecting agree in the field below, the authorized officer of the company certifies, under penalties provided by the laws of Wyoming, that this premium tax return (including accompanying schedules and statements) has been examined and is to the best of the authorized officer’s knowledge, information, and belief, a true, correct and complete premium tax return, made in good faith for the taxable period indicated.
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Attestation (select one)
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(Authorized Officer)
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(Date)
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I:\PREMIUM\Premium Tax Forms\2025\2025 Quarterly Updates\Final\WY2025RRGAnnualV1
10/20/2025
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2025WYRRGAnnualV1
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