Form 303 - Premium Tax Final For Vehicle Companies - 2013
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1CALENDAR YEAR 2013 PREMIUM TAX FINAL FOR VEHICLE COMPANIES
Office of Superintendent of Insurance, 1120 Paseo De Peralta, Santa Fe, NM 87501, P.O. Box 1689, Santa Fe, NM 87504-1689, Room 433
Make check payable to “Office of Superintendent of Insurance”
For calendar year ending December 31, 2013. Original to be filed no later than April 15, 2014 to avoid a penalty (NMSA 59A-6-4)
Company Name: _________________________________________________________
NM Co. # _____________
Company Address: _________________________________________________________
Class: _____________
NAIC:
_________________________________________________________________
_______________
Contact: _________________________________________________________
Phone/Email: _____________________________________________________
DEDUCTIONS ALLLOWED
1. Gross Premiums
2. Return
3.Political
4. Dividends
5. Premiums
6. Net Premiums
received from
premiums
Subdivisions
paid/credited to
received from
on which the New
policies within the
policyholders
Authorized
Mexico tax is
CLASS
State of New Mexico
companies for
based
reinsurance on
(Column 1 minus
NM risks.
2, 3, 4 & 5).
(19.1) Pvt. Passengers Auto
No Fault
(19.2) Other Pvt. Passenger
Auto Liability
(19.3) Commercial Auto No
Fault
(19.4) Other Commercial
Auto Liability
(21.1) Pvt. Passenger Auto-
Physical Damage
(21.2) Commercial Auto-
Physical Damage
(22) Aircraft (All Perils)
Miscellaneous
1.TOTALS
2. Premium Tax Due (3.003% of line 1)
st
nd
3. Less 1
and 2
quarterly taxes paid (include credit taken)
rd
th
4. Less 3
and 4
quarterly taxes paid (include credit taken)
5. Less year 2013 remaining credit not used in line 3 & 4
6.Net Premium Taxes Due
#78
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, 2013.
NOTARY SEAL
____________________________
President/Authorized Signature
Notary Signature _____________________
My Commission Expires _______________
_____________________________
Subscribed and sworn before me this _____ day of _______, 20___
Secretary/Treasurer/Authorized Signature
Form 303
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