Form 301 - Premium Tax Final For Casualty & Misc. Companies - 2011

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PREMIUM TAX FINAL FOR CASUALTY & MISC. COMPANIES

For calendar year ending December 31, 2011.Original to be filed with the Superintendent of Insurance Santa Fe, New Mexico, no later than April 15, 2012.

PLEASE FILL OUT THE FOLLOWING

Company Name: ____________________________________________________________________________

NM Co. # _____________

Company Address: __________________________________________________________________________

Class:

_____________

__________________________________________________________________________

NAIC:

_____________

Contact: __________________________________________________________

Phone/Email: _____________________________________________________

DEDUCTIONS

ALLLOWED

Gross Premiums

Return premiums

Political

Dividends

Premiums

Net Premiums on

received from policies

Subdivisions

paid/credited to

received from

which the New Mexico

within the State of

policyholders

Authorized

tax is based (Column 1

CLASS

New Mexico

companies for

minus 2, 3, 4 & 5).

reinsurance on

NM risks

(6)

Mortgage Guaranty

(10) Financial Guaranty

(11) Medical Malpractice

(13) Group Accident and Health

(14) Credit A & H (Group & Individual)

(15.1) Collectively Renewable A & H

(15.2) Non-Cancelable A & H

(15.3) Guaranteed Renewable A & H

(15.4) Non-Renewable for stated reasons

only

(15.5) Other accident only

(15.7) All Other Accident & Health

(16) Workers’ Compensation

(17.1) Other Liability –Occurrence

(17.2) Other Liability- Claims made

(17.3) Excess Worker’s Compensation

(18) Products liability

(23) Fidelity

(24) Surety

(26) Burglary & Theft

(27) Boiler & Machinery

(28) Credit

(29) Title Guaranty

(29.1) Property Bail Bonds

(30) Warranty

(34) Aggregate Write-ins

1. TOTALS

2. Premium Tax Due (3.003% of line 1)

3. Enter State of Domicile Tax Rate

4. If tax rate on line 3 is greater than 3.003% then enter Retaliatory Tax

5. Less Medical Insurance Pool (50 % credit) Copies of cancelled check(s) to be submitted (if applicable)

6.1 Less Medical Insurance Pool (75 % credit on special acts) Submit copies of cancelled check(s) (if applicable)

7. Less Health Alliance (50% credit) Copies of cancelled check(s) to be submitted (if applicable)

8. Premium Tax Due

9. Less 1st and 2nd quarterly taxes paid (include credit taken)

10. Less 3rd and 4th quarterly taxes paid (include credit taken)

11. Less year 2011 remaining credit not used in line 9 & 10

12. Net Premium Taxes Due

#54

1. All Health Insurance Premium during the 2010 tax year

2. Surtax Due (1% of Line 1)

3. Less 1st and 2nd surtax paid (include credit taken)

4. Less 3rd and 4th surtax paid (include credit taken)

5. Less year 2011 remaining credit not used in line 3 & 4

6. Net Surtax Due (Do not net lines 12 & 6)

#53

Total Amount of Check

Check #

The insurance company above named; whose return for PREMIUM TAX is herein above set forth; that they signed the forgoing Premium Tax returns for and as of the act of said

insurance company by authority of its Board of Directors that they have examined the contents thereof; and that to their best knowledge and belief are true and correct, as

disclosed the books of said insurance company as of December 31, 2011.

_______________________________

Notary Seal

President

Notary Signature _________________________________

_______________________________

My Commission Expires ___________________________

Secretary/Treasurer

Subscribed and sworn before me this ___day of ____________ 20___

Form 301