Form 300 - Remium Tax Final For Life Insurance Companies - 2011
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1PREMIUM TAX FINAL FOR LIFE INSURANCE 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: ____________________________________________________________
Company Co. # ________
Company Address:___________________________________________________________
Class:
__________
___________________________________________________________
NAIC:
__________
Contact: ________________________________________________
Phone/Email:_____________________________________________
DEDUCTIONSALLLOWED
1. Gross
2.
3.
4.
5. Premiums
6. Net Premiums
Premiums
Return
Political
Dividends
received from
on which the New
received from
premiums
Subdivisions
paid/credited
Authorized
Mexico tax is
CLASS
policies within
to
companies
based
the State of New
policyholders
for
(Column 1 minus
Mexico
reinsurance
2, 3, 4 & 5).
on NM risks.
(1) Ordinary Life
(2) Credit Life (GRP and INDV)
(3) Group Insurance
(4) Industrial Insurance
(13) Aggregate write-ins for other
lines
(24)
Group Accident and Health
(24.2) Credit A&H (GRP and Indv.)
(24.3) Collectively Renewable
A&H
(25.1) Non-Cancellable A&H
(25.2) Guaranteed Renewable A&H
(25.3) Non-Renewable A&H
(25.4) Other Accident Only
(25.5) All other A&H
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
st
nd
9. Less 1
and 2
quarterly taxes paid (include credit taken)
rd
th
10. Less 3
and 4
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 Premiums on policies renewed during the 2011 tax year
2. Surtax Due (1% of Line 1)
st
nd
3. Less 1
and 2
surtax paid (include credit taken)
rd
th
4. Less 3
and 4
surtax paid (include credit taken)
5. Less year 2011 remaining credit not used in line 3 & 4
7. Net Surtax Due (Do not net lines 12 and 7)
#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, 2010.
Notary Seal
_____________________________
President
Notary Signature ______________________
My Commission Expires ________________
_____________________________
Secretary/Treasurer
Subscribed and sworn before me this ______ day of ________, 20___
Form 300
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