NEW MEXICO PUBLIC REGULATION COMMISSION
2012 Estimated Premium Tax Report for New Mexico
Filing Status:
Company Name: ______________________________________________________
Address: ______________________________________________________
______________________________________________________
Name or Address change
)
(Please note changes
NM Company Code: ______________
NAIC #: _____________
AMENDED return
Contact Person: ______________________________________
Phone: _____________________________________________
Email _____________________________________________
Filing Period:
st
th
Instructions
1
Quarter Due April 15
nd
th
2
Quarter Due July 15
* Make one check payable to “NMPRC Insurance Division”
rd
th
ue Oct.
3
Quarter D
15
th
th
* Do not inter-mingle premium tax credits with surtax credit
4
Quarter Due Jan. 15
* Complete form in blue or black ink
* Current New Mexico Premium Tax rate is 3.003%
For each Column enter the following:
Life/Health
Casualty
Property
Vehicle
54
54
78
78
1. 25% of tax due in preceding calendar
year............................................................
2. 80% of current tax due this quarter...........
3. Tax credit to be applied.............................
(This line is not to report your company’s credit balance)
4. Amount to be paid
(Greater of 1 or 2, minus 3).......................
Health Insurance Premium Surtax: See NMSA 1978, 59A-6-2 as amended, effective June 17, 2005.
All health insurers and plans shall complete the following:
Surtax
53
1. 25% of tax due in preceding calendar year..............................................
2. 80% of current tax due this quarter..........................................................
3. Tax credit to be applied............................................................................
4. Amount to be paid (Greater of 1 or 2, minus 3).......................................
UNSIGNED REPORTS WILL BE RETURNED
Check Number ______________
Signature of Preparer ___________________________
Check Amount $_____________
Date________________ Phone __________________
For Financial Audit Use
Form 306