Form In-1183 - Statement Of Premiums And Fees For Taxation - Health Maintenance Organizations - 2010 Page 2

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FOR DEPARTMENT USE ONLY
CI377 121/971 ________________________
CI387 121/975 ________________________
STATE OF TENNESSEE
CI360
880/ 992 _______________________
THE DEPARTMENT OF COMMERCE AND INSURANCE
P.O. BOX 198983
Nashville, TN 37219-8983
CI362
880/ 993 _______________________
(615) 741-1670
STATEMENT OF PREMIUMS AND FEES FOR TAXATION
(To be Filed On Or Before March 1)
HEALTH MAINTENANCE ORGANIZATIONS
Posted by
Company Name
Contact Person
Amended
Address (No. & Street)
E-Mail Address
Calendar Year
NAIC CO.CODE
City, State & Zip
Phone Number/ Fax Number
Date Admitted to TN
Domiciliary State
Premiums
HMO Tax
1. Premium Tax (5.5% of all gross dollars collected from an enrollee or on an enrollee’s behalf)
$
$
$
$
2. Premium Tax (5.5% of all TennCare dollars collected from an enrollee or on an enrollee’s behalf)
$
3. Total Tax (Sum of Lines 1 and 2)
$
4a. Amount Paid TN Insurance Dept. Previous Three Quarters: Commercial Premium Tax
$
4b. Amount Paid TN Insurance Dept. Previous Three Quarters: TennCare Premium Tax
$
5. Total Deductions (Sum of Lines 4a and 4b)
$
6. Total Tax Due (Line 5 minus Line 7)
$
195.00
7.
Annual Statement Filing Fee
$
445.00
8.
Renewal Fee for Certificate of Authority
$
9. Total Amount Due (Sum of Lines 8,9, and 10)
Make remittance payable to: TENNESSEE DEPT. OF COMMERCE & INSURANCE
Audited By ___________________ Date ____ /____ /_______
STATEMENT OF PREMIUMS AND FEES FOR TAXATION MUST OBTAIN ORIGINAL SIGNATURE AND NOTARY
STATE OF ___________________________
COUNTY OF ___________________________
I, _________________________________________ , do hereby make oath that I am ____________________________________________
(Officer’s Name)
(Official Title)
of the _____________________________________________________________________________________________________________
(Company Name)
and that the foregoing Statement of Premiums and Fees for Taxation is true to the best of my knowledge, information and belief.
___________________________________________
___________________________
Signature of Officer
Notary Public
(SEAL)
Subscribed and Sworn before me __________________
Date
My commission expires
__________________
Date
HMO Annual Form Rev 12/2010
Page 2 of 3
FORM IN-1183

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