Form 25-100 - Texas Annual Insurance Premium Tax Report
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225-100
b.
b
PRINT FORM
RESET FORM
(Rev.2-13/24)
Texas Annual Insurance Premium Tax Report
(Licensed Insurance Companies and Miscellaneous Organizations)
under Chapters 552 and 559, Government Code,
You have certain rights
to review, request and correct information we have on file about you.
A report must be filed even if no tax is due.
a. T Code
Contact us at the address or phone number listed on this form.
71100
c. Taxpayer number
d. Filing period
f. Due date
e.
YEAR ENDING 12-31-2012
g. Taxpayer name and tax report mailing address (Make any necessary name and address changes below.)
IMPORTANT
h.
Blacken this box if your mailing
address has changed. Show changes
1.
beside the preprinted information.
j.
i.
or
1. Gross life premiums
HMO revenues (Whole dollars only)
1.
2. Non-taxable premiums (From Form 25-205)
2.
3. Taxable premiums (Item 1 minus Item 2)
3.
smaller
4. Enter the
of Item 3 or $450,000
4.
8 7 5 . 0
5. Tax rate
5.
6. Tax due (Multiply Item 4 by Item 5. If less than zero, see instructions on back.) (Dollars and cents)
6.
over
7. Enter the premiums
$450,000 (Whole dollars only)
7.
1 , 7 5 0
8. Tax rate
8.
9. Tax due (Multiply Item 7 by Item 8)
9.
10. TOTAL TAX DUE (Item 6 plus Item 9)
10.
11. Gross accident and health premiums (Whole dollars only)
11.
12. Employee contribution for benefit plans (Not included in Item 11)
12.
13. Non-taxable premiums (From Form 25-205)
13.
14. Taxable accident and health premiums (Item 11 plus Item 12 minus Item 13)
14.
15. Tax rate
15.
1
, 7
5
0
16. TOTAL TAX DUE (Multiply Item 14 by Item 15. If less than zero, see instructions.)
16.
17. Gross property and/or casualty or title premiums (Whole dollars only)
17.
18. Non-taxable premiums (From Form 25-205)
18.
19. Taxable premiums (Item 17 minus Item 18)
19.
20. Tax rate (See instructions)
20.
21. TOTAL TAX DUE (Multiply Item 19 by Item 20. If less than zero, enter 0.)
21.
22. TOTAL PREMIUM TAX DUE (Total of Items 10, 16 and 21. If less than zero, enter 0.)
22.
23. Credits (See instructions)
23.
XXXXXXXXXXXXX
24. Assessment and CAPCO credits
24.
25. NET PREMIUM TAX DUE (Item 22 minus Items 23 and 24. If less than zero, enter 0.)
25.
26. Total prior payments
26.
27. PREMIUM TAX DUE AND PAYABLE (Item 25 minus Item 26)
27.
* * * DO NOT DETACH * * *
Form 25-100 (Rev.2-13/24)
28. Penalty and interest (See instructions on back.)
28.
29. TOTAL AMOUNT DUE AND PAYABLE (Item 27 plus Item 28)
29.
Taxpayer name
k.
l.
T Code
Taxpayer number
Period
I declare the information in this document and all attachments is true and correct
to the best of my knowledge and belief.
Authorized agent
Preparer's name (Please print)
Make the amount in Item 29
Mail to: COMPTROLLER OF PUBLIC ACCOUNTS
payable to:
P.O. Box 149356
Daytime phone
Date
STATE COMPTROLLER
Austin, TX 78714-9356
(Area code & number)
For information about Insurance Tax,
call 1-800-252-1387 or 512-463-4600.
111 A
Details are also available online at
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