Form 25-122 - Texas Annual Insurance Tax Report - Supplement
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125-122
b.
(Rev.12-15/6)
e.
d. Filing period
71240
a. T Code
Taxpayer name
c. Taxpayer number
1. Policy number
2. Name of insurer
3. Gross premium charged
4. Premium allocated to Texas
5. Effective date of policy
.00
.00
6. Type of insurance
1. Policy number
2. Name of insurer
3. Gross premium charged
4. Premium allocated to Texas
5. Effective date of policy
.00
.00
6. Type of insurance
1. Policy number
2. Name of insurer
3. Gross premium charged
4. Premium allocated to Texas
5. Effective date of policy
.00
.00
6. Type of insurance
1. Policy number
2. Name of insurer
3. Gross premium charged
4. Premium allocated to Texas
5. Effective date of policy
.00
.00
6. Type of insurance
1. Policy number
2. Name of insurer
3. Gross premium charged
4. Premium allocated to Texas
5. Effective date of policy
.00
.00
6. Type of insurance
1. Policy number
2. Name of insurer
3. Gross premium charged
4. Premium allocated to Texas
5. Effective date of policy
.00
.00
6. Type of insurance
Total premiums allocated to Texas
under Chapters 552 and 559, Government Code,
for this page only.
to review, request and correct information we have on file about you. Contact
.00
us at the address or phone number listed on the report.
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