Form 25-205 - Computation Of Non-Taxable Premiums
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225-205
CLEAR FORM
(Rev.11-03/10)
COMPUTATION OF NON-TAXABLE PREMIUMS
Complete this form and file it with your "Texas Annual Insurance Premium Tax Report," Form 25-100.
Under Ch. 559, Government Code, you are entitled to review, request, and correct information we have on file about you, with limited exceptions in accordance with Ch. 552, Government Code. To request
information for review or to request error correction, contact us toll free at 1-800-252-1387.
Taxpayer name
Taxpayer number
Tax year
This schedule is used to compute non-taxable premiums. The Comptroller may request additional information concerning the premiums reported as non-taxable. Any amounts reported as non-taxable must
be included in the gross premium amount reported on the Texas Annual Insurance Premium Tax Report, Form 25-100.
Column A
Column B
Column C
Column D
DO NOT WRITE IN SHADED AREAS.
Section I
Section I
Section II
Section III
Life
HMO
Accident & Health
Property & Casualty
Premiums
Revenues
Premiums
Premiums
1. Insurers' contributions for employee benefit plans .............................................
$ __________________
$ __________________
$ __________________
$ __________________
2. Article 4.11, Texas Insurance Code:
(a) Returned Premiums .....................................................................................
__________________
__________________
__________________
__________________
(b) Dividends applied to purchase paid-up additions ........................................
__________________
__________________
__________________
__________________
(c) (1) Premiums from the Treasury of the United States for insurance
contracted for by the Federal government in accordance with the Federal
Social Security Act, such as Medicare
(2) Prior to September 1, 2003, premiums from the Treasury of the
United States or State of Texas for Medicaid and the Children's Health
Insurance Program (CHIP) ..........................................................................
__________________
__________________
__________________
__________________
(d) Premiums on group policies for groups consisting of a single
nonprofit trust established to provide coverage primarily for
employees of municipal, county, or hospital districts in Texas ....................
__________________
__________________
__________________
__________________
(e) Stop Loss Coverages issued to HMOs ........................................................
__________________
__________________
__________________
__________________
3. Title 8, Chapter 1551, Texas Ins. Code, (*Former Art. 3.50-2), Texas
Employees Group Benefits Act ..........................................................................
__________________
__________________
__________________
__________________
4. Title 8, Chapter 1601, Texas Ins. Code, (*Former Art. 3.50-3), Uniform
Insurance Benefits Act for employees of the University of Texas System
and the Texas A&M University System ..............................................................
__________________
__________________
__________________
__________________
5. Title 8, Chapter 1575, Texas Ins. Code, (*Former Art. 3.50-4), Texas Public
School Employees Group Benefits Program ......................................................
__________________
__________________
__________________
__________________
6. Title 8, Chapter 1576, Texas Ins. Code, (*Former Art. 3.50-4A), Group
Long-Term Care Insurance for Public School Employees and Title 8,
Chapter 1577, Texas Ins. Code, (*Former Art. 3.50-4A), Required
Availability of Insurance for School District Employees and Retirees ................
__________________
__________________
__________________
__________________
7. Article 3.71, Texas Insurance Code, Texas 65 Health Insurance
Plans ...................................................................................................................
__________________
__________________
__________________
__________________
8. Section 8909, Title 5, United States Code, Federal Employees Health
Benefits Program ................................................................................................
__________________
__________________
__________________
__________________
9. Article 27.05, Texas Insurance Code, children's health benefit plan .................
__________________
__________________
__________________
__________________
10. Article 4.10, Texas Insurance Code
(a) Returned premiums .....................................................................................
__________________
__________________
__________________
__________________
(b) Dividends paid policyholders .......................................................................
__________________
__________________
__________________
__________________
11. Federal Crop Insurance Corporation (FCIC) multi-peril crop preemption ..........
__________________
__________________
__________________
__________________
12. Article 5.35-3, Texas Insurance Code, Property Protection Program
for Underserved Areas .......................................................................................
__________________
__________________
__________________
__________________
13. Total Non-taxable Premiums (Enter total here and on the appropriate
item of the premium tax report, Form 25-100.) ...................................................
$ _________________
$ _________________
$ _________________
$ _________________
(Enter on Form 25-100, Item 2)
(Enter on Form 25-100, Item 2)
(Enter on Form 25-100, Item 13)
(Enter on Form 25-100, Item 18)
*Articles recodified by Acts 2001, 77th Leg., ch. 1419, § 31, effective June 1, 2003.
SEE ADDITIONAL INFORMATION ON BACK.
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