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Nue Commissioners Large Cases Division Ballaugh House 73/79 Lower Mount Street Dublin 2, Ireland STAMP DUTY ON POLICIES OF INSURANCE (NON-LIFE) Payment under Composition Agreement SECTION 5, STAMP DUTIES CONSOLIDATION ACT, 1999 Insurer s statement for the quarter ending: D D M M Y Y Y Y D D M M Y Y Y Y Y Y Y Name of Insurer: Address: Number of Policies issued as per schedule attached: Total Stamp Duty 1.00 per policy: Method of Payment ( as appropriate) Cheque/Draft.

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