Form 300 - Calendar Year 2013 Premium Tax Final For Life Companies

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CALENDAR YEAR 2013 PREMIUM TAX FINAL FOR LIFE 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: ____________________________________________________________

Company Co. # ________

Company Address:___________________________________________________________

Class:

__________

___________________________________________________________

NAIC:

__________

Contact: ________________________________________________

Phone/Email:_____________________________________________

DEDUCTIONSALLLOWED

1. Gross Premiums

2.Return

3.Political

4. Dividends

5. Premiums

6. Net Premiums on

received from

premiums

Subdivisions

paid/credited to

received from

which the New Mexico

CLASS

policies within the

policyholders

Authorized

tax is

State of New

companies for

based

Mexico

reinsurance on

(Column 1 less

NM risks.

2, 3, 4 & 5).

(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. 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

Not presently being assessed per Order of OSI.

See DOI Bulletin 2009-008

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 1

and 2

quarterly taxes paid (include credit taken)

10. Less 3

and 4

quarterly taxes paid (include credit taken)

11. Less year 2013 remaining credit not used in line 9 & 10

12.Net Premium Taxes Due

#54

1. All Health Insurance Premiums on policies during the 2013 tax year

2. Surtax Due (1% of Line 1)

3. Less 1

and 2

surtax paid (include credit taken)

4. Less 3

and 4

surtax paid (include credit taken)

5. Less year 2013 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, 2013.

Notary Seal

_____________________________

President/Authorized Signature

Notary Signature __________________________

My Commission Expires ____________________

__________________________________

Secretary/Treasurer /Authorized Signature

Subscribed and sworn before me this ______ day of ________, 20___

Form 300