Form 25-205 - Computation Of Non-Taxable Premiums
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125-205
(Rev.12-01/8)
COMPUTATION OF NON-TAXABLE PREMIUMS
Complete this form and file it with your "Texas Annual Insurance Premium Tax Report," Form 25-100.
Under Ch. 559, Government Code, you are entitled to review, request, and correct information we have on file about you, with limited exceptions in accordance with Ch. 552, Government Code. To request
information for review or to request error correction, contact us toll free at 1-800-252-1387.
Taxpayer name
Taxpayer number
Tax year
This schedule is used to compute non-taxable premiums. Any amounts reported as non-taxable must be included in the gross premium amount reported on the Texas Annual Insurance Premium Tax Report,
Form 25-100. The Comptroller may request additional information concerning the premiums reported as non-taxable.
Column A
Column B
Column C
Column D
DO NOT WRITE IN SHADED AREAS.
Section I
Section I
Section II
Section III
Life
HMO
Accident & Health
Property & Casualty
Premiums
Revenues
Premiums
Premiums
1. Company contributions for employee benefit plans ........................................... $ __________________
$ __________________
$ __________________
$ __________________
2. Article 4.11, Texas Insurance Code:
(a) Returned Premiums ....................................................................................
__________________
__________________
__________________
__________________
(b) Dividends applied to purchase paid-up additions ........................................
__________________
__________________
__________________
__________________
(c) Premiums from the Treasury of the United States or State of Texas
for the purpose of providing welfare benefits such as Medicare
and Medicaid ...............................................................................................
__________________
__________________
__________________
__________________
(d) Premiums on group policies in which the group consists of a single
nonprofit trust established to provide coverage primarily for employees
of municipal, county, or hospital districts in Texas ......................................
__________________
__________________
__________________
__________________
(e) Stop Loss Coverages issued to HMOs .......................................................
__________________
__________________
__________________
__________________
3. Article 3.50-2, Texas Insurance Code, Texas Employees Uniform
Group Insurance Benefits Act ............................................................................
__________________
__________________
__________________
__________________
4. Article 3.50-3, Texas Insurance Code, Texas State College and
University Employees Uniform Group Insurance Benefits Act ...........................
__________________
__________________
__________________
__________________
5. Article 3.50-4, Texas Insurance Code, Texas Public School Employees
Group Insurance Benefits Act ............................................................................
__________________
__________________
__________________
__________________
6. Article 3.50-4A, Texas Insurance Code, Texas Public School Employees
Group Long-Term Care Insurance Program and Article 3.50-4A, Texas
Insurance Code, Insurance for School District Employees and Retirees ..........
__________________
__________________
__________________
__________________
7. Article 3.71, Texas Insurance Code, Texas 65 Health Insurance
Plans ..................................................................................................................
__________________
__________________
__________________
__________________
8. Section 8909, Title 5, United States Code, Federal Employees Health
Benefits Program ...............................................................................................
__________________
__________________
__________________
__________________
9. Article 27.05, Texas Insurance Code, Children's Health Benefit Plan and
Chapter 109, Title 2, Health and Safety Code, Texas Healthy Kids Corporation ..
__________________
__________________
__________________
__________________
10. Article 4.10, Texas Insurance Code
(a) Returned premiums .....................................................................................
__________________
__________________
__________________
__________________
(b) Dividends paid policyholders .......................................................................
__________________
__________________
__________________
__________________
11. FCIC multi-peril crop preemption .......................................................................
__________________
__________________
__________________
__________________
12. Article 5.35-3, Texas Insurance Code, Property Protection Program
for Underserved Areas .......................................................................................
__________________
__________________
__________________
__________________
13. Total Non-taxable Premiums (Enter total here and on the appropriate
item of the premium tax report, Form 25-100.) ..................................................
$ _________________
$ _________________
$ _________________
$ _________________
(Forward to: 25-100, Item 2)
(Forward to: 25-100, Item 2)
(Forward to: 25-100, Item 13)
(Forward to: 25-100, Item 18)
SEE ADDITIONAL INFORMATION ON BACK.
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