Form 309 - New Mexico Public Regulation Commission
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1NEW MEXICO PUBLIC REGULATION COMMISSION
Financial Audit Bureau
COMMISSIONERS
P.O. Box 1269
1120 Paseo de Peralta
DISTRICT 1 JASON MARKS
Santa Fe, NM 87504-1269
DISTRICT 2 PATRICK H. LYONS, CHAIRMAN
505-827-5781
DISTRICT 3 JEROME D. BLOCK, VICE CHAIRMAN
DISTRICT 4 THERESA BECENTI-AGUILAR
DISTRICT 5 BEN L. HALL
Superintendent of Insurance
John G. Franchini
Insured’s name and address:
SS#/Tax Id #: _____________
________________________________
Telephone #: _____________
________________________________
________________________________
Make Check payable to “NMPRC Insurance Division”
Pursuant to Section 59A-6-2 (5) NMSA 1978, each unauthorized insurer that has assumed a contract or policy of insurance
directly or indirectly form such policies remaining in force in New Mexico, except that this provision shall not apply if a ceding
insurer continues to pay the tax provided in this Section as to such policy or contract. (Premium Tax must be paid on a yearly
basis).
Description of coverage: ______________________________________________________
________________________________________________________________________________________________________
______________________________________________
Company/Insurer: _______________________
Agent: ___________________________
Address: _______________________________
Address: _________________________
______________________________________
________________________________
Amount of premium charged:
$____________________
Premium tax due amount (3.003% of previous line):
$____________________
(DO NOT WRITE ON THIS LINE) Total ACCOUNT #54
$____________________
(DO NOT WRITE ON THIS LINE) Total ACCOUNT #78
$____________________
PLEASE COMPLETE THE FOLLOWING:
____________________________ ___________
Print or type preparer’s name
Date
PLEASE RECORD
____________________________
Check Number: ______________
Phone Number
_________________________________________
Amount Remitted: ____________
Preparer’s Signature & Title
Form 309
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