Form Ins-Ptx-Thpsc - Statement Of Taxes And Fees

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STATE OF IDAHO
FOR DEPARTMENT USE ONLY
DEPARTMENT OF INSURANCE
0560
700 WEST STATE STREET, 3rd FLOOR
1025
PO BOX 83720
1315-10
BOISE, ID 83720-0043
TOTAL
2014 STATEMENT OF TAXES AND FEES
HOSPITAL AND PROFESSIONAL SERVICE CORP.
C/A NO.
NAIC NO.
COMPANY NAME
FOR CALENDAR
YEAR
ENDING
DECEMBER 31, 2014
MAILING ADDRESS
CITY
STATE
ZIP CODE
DOMICILE STATE
RECAP OF TAXES AND FEES
1. HOSPITAL AND PROFESSIONAL SERVICE CORPORATION TAX ( SCHEDULE A )
$_________________________________
2. TOTAL OF ALL ATTACHED SELF-FUNDED PLAN(S) TAX ( SCHEDULE C )
$_________________________________
vi.:
500.00
IDAPA 18.01.44.03.a.
3
ANNUAL CONTINUATION FEE for Calendar Year 2015,
$
Payment of fee must be included
.
4
ADD PENALTY, IF DUE ($25.00 per day of delinquency -
$_________________________________
Idaho Code § 41-3928 and 41-3427)
5
TOTAL AMOUNT ENCLOSED:
$_________________________________
Make check payable to: Idaho Department of Insurance
There will be a $20.00 charge on all returned checks - Idaho Code § 28-22-105
Indicate if payment is by EFT ________.
Your canceled check is your receipt
By my signature below, being duly sworn upon oath, I declare that the premium tax report is a complete, true and correct statement of all
premiums and fees on business written by said company during the year ending December 31, 2014 on insurance of property or risks resident or
located in Idaho.
______________________________________
____________________________________
Contact person
Signature of Officer (required)
______________________________________
____________________________________
Telephone number
Ext.
Title
______________________________________
____________________________________
Email address
Date
INS-PTX-THPSC (08-14)
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