Form In-0581 - Life And Accident And Health Companies - Tennessee Department Of Commerce And Insurance
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4FOR DEPARTMENT USE ONLY
CI373 121/970 ____________________
CI377 121/971 ____________________
STATE OF TENNESSEE
THE DEPARTMENT OF COMMERCE AND INSURANCE
P.O. BOX 198983
CI378
122/551 _______________________
Nashville, TN 37219-8983
(615) 741-1670
STATEMENT OF PREMIUMS AND FEES FOR TAXATION
CI364 880/554 _______________________
(To Be Filed On Or Before March 1)
LIFE AND ACCIDENT AND HEALTH COMPANIES
Scanned
Company Name
Contact Person
Amended
Address (No. & Street)
E-Mail Address
Calendar Year
NAIC CO.CODE
City, State & Zip
Phone Number/ Fax Number
Date Admitted to TN
Domiciliary State
Premiums
Tax
1. Life Premium Tax – (1.75% on taxable direct life premiums)
$
$
2. Accident and Health Premium Tax – (1.75% on taxable direct A & H premiums)
$
$
Do Not list a negative Tax amounts on any of the above lines; if negative, enter zero (0)
*3. Premiums, if any, required to balance with Schedule T
$
4. Total premiums reported on Schedule T (Tennessee Business)
$
$150.00 MINIMUM TAX
5. Total Tax (Sum of Lines 1 and 2)
( If less than $150.00, Enter
)
$
6a. Amount Paid TN Insurance Dept. Previous Three Quarters: Life Premium Tax
$
6b. Amount Paid TN Insurance Dept. Previous Three Quarters: Accident and Health Premium Tax
$
7a. TNInvestco Tax Credit (See instructions- Co. must include original Certificate for this cal. tax yr.)
$
7b. Credit Due Company for the TN Life and Health Insurance Guaranty Association Assessment
$
8. Total Deductions (sum of lines 6 thru 7b.) Note: Do not take credit for prior year overpayments
$
9. Total Tax Due (Line 5 Minus Line 8)
$
10. Annual Statement Filing Fee (Must be Remitted Even if Credit or Refund is Due)
$
515.00
11. Retaliatory Tax (As Computed in Schedule A)
$
12. TOTAL AMOUNT DUE (Sum of lines 9, 10, and 11)
$
Please attach a copy of Tennessee business page from the Annual Statement.
Make remittance payable to: TENNESSEE DEPT. OF COMMERCE & INSURANCE
* Explanation of Non-Taxable Premiums Required to Balance With Schedule T of Annual Statement. This exemption includes all annuity premiums
and premiums or considerations received under life insurance policies issued in connection with any pension plan, annuity plan, or profit sharing plan
qualified for Federal Income Tax advantage under part 1, subchapter D, subtitle A, IRS Code of 1954, including any amendments thereto and
successors thereof, and to any trust qualified under Section 501 (a). IRS Code of 1954, including amendments and successors thereto.
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Form IN-0581 Life Company Annual Form Rev 12/2012
Page 1 of 4
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