Form In 0578 - Companies Other Than Life - State Of Tennessee The Department Of Commerce And Insurance
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1
2
3FOR DEPARTMENT USE ONLY
CI374 121/972 ________________________
CI393 131 ___________________________
STATE OF TENNESSEE
THE DEPARTMENT OF COMMERCE AND INSURANCE
CI359 880/300 ________________________
P.O. BOX 198983
Nashville, TN 37219-8983
(615) 741-1670
CI383 125 ___________________________
Estimated Quarterly Statement of Premiums and Fees for Taxation
COMPANIES OTHER THAN LIFE
FEIN#
Company Name
Contact Person
Due Dates:
Calendar Year
June 1
August 20
Address (No. & Street)
E-Mail Address
NAIC CO.CODE
December 1
City, State & Zip
Phone Number/ Fax Number
Date Admitted to TN
Domiciliary State
This Return Must Be Completed and Filed Even if There Were No Premiums Written
Est. tax must equal 25% OF ACTUAL tax paid during the ENTIRE PREVIOUS
ESTIMATED
YEAR; OR, AT LEAST 80% OF Premium tax Paid on QUARTERLY FILING
Premiums
ESTIMATED Tax
finally shown to be due for the current quarter (based on estimated premium)
in order to avoid Penalty
1. Premium Tax -- (
2.5% on estimated premiums other than Workmen’s Comp)
$
$
See Tenn. Code Ann. § 56
4-205
-
2. Workers’ Compensation Tax
-- (4% on estimated Workmen’s Comp Premiums)
$
$
See Tenn. Code Ann. § 56
4-206
-
3. Fire Marshal Tax
XXXXXXXXXXXXXX
$
-- (as computed in Schedule B, pg. 2)
4. Workers’ Compensation Surcharge
XXXXXXXXXXXXXX
$
-- (as computed in Schedule E , pg. 2)
5. Total Estimated Premiums and Estimated Tax
$
$
(add lines 1 thru 5)
6. LESS: TNINVESTCO Credit (
only certified investors who have been allocated a
XXXXXXXXXXXXXX
$
premium tax credit pursuant to TCA 4-28-101 et.seq. are eligible for this credit. Do not
use more credit than the total tax listed on lines 1 and 2 above).
7. Net Estimated Premium, Workers’ Comp, Fire Marshal Tax and
XXXXXXXXXXXXXX
$
PAY THIS AMOUNT
Workers’ Comp Surcharge
(Line 5 minus line 6)
Do not list negative Tax amounts on any of the above lines; if negative, enter zero (0)
Make remittance payable to: TENNESSEE DEPT. OF COMMERCE & INSURANCE
IN-0578
Other Than Life Quarterly Tax Form Rev 3/2014
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