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Form Iip-R - Annual Industrial Insurance (Workers Compensation) Reconciliation Premium Tax Return - 2012

Nevada Department of Taxation

Due Date

_______________

Taxpayer ID:

1550 College Parkway Ste 115

Federal ID: ______________________

March 15, 2013

Carson City, NV 89706

Premium Tax: ______________________

Phone: (775) 684-2000

Retaliatory Tax: ______________________

Fax: (775) 684-2020

Total Remittance: ______________________

ANNUAL INDUSTRIAL INSURANCE (WORKERS COMPENSATION) RECONCILIATION

PREMIUM TAX RETURN 2012

Department Use Only

Amount: _____________________________

Check No: _____________________________

Date Rec’d: _____________________________

Initials: _____________________________

(A)

(B)

Net Quarterly Taxable Premiums/Considerations

REPORTED

ACTUAL

1. March 31. 2012

2. June 30, 2012

3. September 30, 2012

4. December 31. 2012

5. Total Premiums/Considerations (Add Lines 1 through 4)

6. Total Industrial Insurance Premiums (Line 5, column B – Must agree with Schedule 1, Line 3A)

7. Gross Premium Tax (3.5% of Line 6 – Must agree with Schedule 1, Line 4 A)

8. Industrial Insurance Credit (Division of Industrial Relations) (NRS 680B.036)

9. Subtotal of Net Industrial Insurance Premium Tax Due (Line 7 minus Line 8)

10a.

Home Office Credit, if qualified (NRS 680B.050) 50% or .5 of Line 9 (Form PT-04 and required documents must be attached)

10b. Amount of Ad Valorem Taxes Paid, if qualified for Home Office Credit (NRS 680B.050)

10b.

10c. Max Credit Allowed

10c.

10d. Allowable Home Office Credits

10d.

11. Property/Casualty Guaranty Association Credit (NRS 687A)

11.

12. Total Cash Payments made with Quarterly Returns (Do Not Include any Penalty and/or Interest)

12.

13. Net Industrial Insurance Premium Tax Due (Line 9 minus Lines 10d through 13 plus Line 14)

13.

14. Penalty ( See Instructions for rate)

14.

15. Daily Interest. Premium Tax Due (Line 15) multiplied by .00049315068 times the number of days late

15.

16. Total Industrial Insurance Premium Tax Due (Line 15 plus Lines 16 and 17)

16.

If Line 16 results in an overpayment, the overpayment will be reviewed for possible refund.

Amount of overpayment

Please indicate if this company files any of the following returns (Please check all that apply)

Insurance Premium Tax

Industrial Insurance Premium Tax

Retaliatory Tax

NRS REQUIRES THIS RETURN MUST BE SIGNED

I hearby declare under penalty of perjury that this premium tax report (including any accompanying schedules and statements) has been

examined by me and is true, correct and complete report.

Signature of Taxpayer or Authorized Agent

Printed Name of Taxpayer or Authorized Agent

Date

Telephone

IIP-R

Revised 12-06-12

Form Iip-R - Annual Industrial Insurance (Workers Compensation) Reconciliation Premium Tax Return - 2012

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