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Industrial Insurance Premium Tax Annual Return (Workers Compensation) Instructions

A COPY OF THE NEVADA PAGE FROM ANNUAL STATEMENT MUST BE ATTACHED

This form is to be used if you paid under $2000 in Insurance Premium Tax during the previous year. The Nevada premium tax rate is

3.5%. (Retaliatory statues, NRS 680A.330 requires you to use the higher tax rate charged by your domiciliary state).

Schedule 1

Line 1 Gross Premiums/Considerations. Defined as all direct premiums written during the year for workers compensation.

Line 2 Dividends Paid or Credited to Policy Holders

Line 3 Gross Premiums written minus Dividends paid or credited to policy holders.

Line 4 Taxes Payable. Amount of premium tax due.

Line 5 Retaliatory Assessment

Annual Return

Line 1 Total Premiums/Considerations Enter the amount of taxable net direct Industrial Insurance premiums written and net

considerations received this year. (Must agree with Schedule 1, Line 1)

Line 2 Gross Industrial Insurance Premium Tax Enter the amount of Gross Premium Tax. Multiply Line 1 by 3.5% or .035.

Line 3 Industrial Insurance Credit Enter the amount paid to Division of Industrial Relations for the year. Each insurer providing

industrial insurance in this state is entitled to a credit against the premium tax paid equal to the assessment paid to Division of

Industrial Relations. (NRS 680B.036). This credit is to be applied only against the premium tax for the year in which the assessment

to the Division of Industrial Relations was paid. The Credit can not be applied against future premium tax liability.

Line A. Subtotal Enter in premium tax due. Line 2 minus Line 3.

Line 4a Home Office Credit. 50% or .5 of Line A. NRS 680B.050 provides that insurers who maintain a “home” or “regional” office

may be entitled to a credit against tax to be paid. It provides for a 50 percent credit for taxes due. Each insurer claiming a home or

regional home office credit must have a certified copy of the deed to the property in the name of the insurer on file with the

Department.

Line 4b Ad Valorem Taxes Enter the amount of ad valorem Taxes paid during this year. NRS 680B.050(1) provides for credit for ad

valorem taxes actually paid upon the home office or regional home office together with the land, as reasonably required for the

convenient use of the office, upon which the home office or regional home office is situated. Further, the insurer must provide

certified copies of the billing by local authorities for the ad valorem taxes in addition to a receipt for proof of payment.

Line 4c Max Credit allowed Enter max credit allowed. Multiply Line 2 by 80% or .80. NRS 680B.050(1) imposes a limit on the

total amount of the credit that may be obtained. The credits may not reduce the total amount of taxes payable to less than 20 percent

of the amount of gross premium taxes payable.

Line 4d Enter the available Home Office Credit and Ad Valorem taxes credit. Add lines 4a and 4b. Compare to line 4c. Enter the

lesser of the two.

Line 5 Enter the amount of Net Premium Tax due. Line A minus 4d.

Line 6 Enter the amount of Property/Casualty Guaranty Association credit to be used this year.

Line B Enter the amount due to you for overpayments made in prior reporting periods for which you have received a Department of

Taxation Credit Notice. Monthly notices received from the Department are not cumulative. Do not take the credit if you have applied

for a refund. NOTE: Only credits established by the Department may be used.

Line C Enter the amount of Overpayments refunded by Nevada during the calendar year.

IIP-A

Revised 11-22-11

Form Iip-A - Annual Industrial Insurance (Workers Compensation) Premium Tax Return - 2012 Page 3