STATE OF NEW MEXICO
OFFICE OF SUPERINTENDENT OF INSURANCE
Financial Audit Bureau
1120 Paseo De Peralta, Room 433 Santa Fe, New Mexico, 87501
P.O. Box 1689, Room 433, Santa Fe, New Mexico, 87504-1689
505-827-5781 or 1-855-427-5674
2014 Estimated Quarterly Premium Tax Report
Filing Status:
Company Name: ______________________________________________________
Address: ______________________________________________________
______________________________________________________
Name or Address change
)
(Please note changes
NM Company Code: ______________ Company Class ________
NAIC #: _____________
AMENDED
Reason:__________________
___________________
Contact Person: ______________________________________
Phone: _____________________________________________
Email: _____________________________________________
Filing Period:
st
th
Instructions:
1
Quarter Due April 15
nd
th
2
Quarter Due July 15
* Make one check payable to “Office of Superintendent of Insurance or OSI”
rd
th
ue Oct.
3
Quarter D
15
th
th
* Applicable Credits are transferable, written confirmation is needed.
4
Quarter Due Jan. 15
* Current New Mexico Premium Tax rate is 3.003%
* Late, non-filing, unsigned and/or incomplete reports will be assessed a
penalty pursuant to NMSA 1978, Section 59A-6-4.
For each Column enter the following:
Life/Health
Casualty
Property
Vehicle
54
54
78
78
1. 25% of tax due in preceding calendar
year ...............................................................
2. 20% of tax due for this quarter...........
3. Tax credit to be applied.............................
(This line is to be used to report ONLY the applicable credit to be applied)
4. Amount Due (
)..............
Greater of 1 or 2, minus 3
All health insurers and plans shall complete the following:
Surtax
53
1. 25% of tax due in preceding calendar year..............................................
2. 20% of tax due for this quarter..........................................................
3. Tax credit to be applied............................................................................
(This line is to be used to report ONLY the applicable credit to be applied)
4. Amount Due (
).............................................................
Greater of 1 or 2, minus 3
Check Number ______________
Check Amount $_____________
Signature of Authorized Preparer _______________________________
Date__________________
The signature for the Authorized Preparer denotes: 1. The Authorized Preparer is authorized to sign and submit this report. 2. The
Authorized Preparer confirms the contents of this report are true and correct to the best of the Authorized Preparer’s knowledge.
Postmarked _______
Form 306
revised 12-9-14
Initials
________