Form 25-205 - Computation Of Non-Taxable Insurance Premiums

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CLEAR FORM
25-205
(Rev.12-12/18)
You have certain rights under Chapters 552 and 559, Government
Code, to review, request and correct information we have on
Computation of Non-Taxable Insurance Premiums
file about you. To request information for review or to
request error correction, contact us 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.
•
Column A
Column B
Column C
Column D
Complete this form and file it with your "Texas Annual Insurance
Section I
Section I
Section II
Section III
Premium Tax Report," Form 25-100.
Life
HMO
Accident & Health
Property & Casualty
•
Do NOT write in shaded areas.
Premiums
Revenues
Premiums
Premiums
1. Insurers' contributions for employee benefit plans ............................................
$ ___________________
$ __________________
$ __________________
$ ___________________
2. Chapter 222, Texas Insurance Code:
(a) Returned Premiums ....................................................................................
___________________
__________________
__________________
___________________
(b) Dividends applied to purchase paid-up additions ........................................
___________________
__________________
__________________
___________________
(c) Premiums received from the U.S. Treasury for Medicare insurance and
premiums under Medicare Advantage (MA) Parts C & D, administered
by the Centers for Medicare and Medicaid Services (CMS). .......................
___________________
__________________
__________________
___________________
(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. Chapter 1551, Texas Insurance Code, Texas
Employees Group Benefits Act ...........................................................................
___________________
__________________
__________________
___________________
4. Chapter 1601, Texas Insurance Code, Uniform
Insurance Benefits Act for Employees of the University
of Texas System and the Texas A&M University System ...................................
___________________
__________________
__________________
___________________
5. Chapter 1575, Texas Insurance Code, Texas Public
School Employees Group Benefits Program and
Chapter 1579, Texas Insurance Code, Texas School
Employees Uniform Group Health Coverage ...................................................
___________________
__________________
__________________
___________________
6. Chapter 1576, Texas Insurance Code, Group Long-Term
Care Insurance for Public School Employees ...................................................
___________________
__________________
__________________
___________________
7. Chapter 1505, Texas Insurance Code, Group Health
Insurance Plans for Persons 65 Years of Age or Older ......................................
___________________
__________________
__________________
___________________
8. Section 8909, Title 5, United States Code, Federal Employees Health
Benefits Program ................................................................................................
___________________
__________________
__________________
___________________
9. Chapter 1502, Texas Insurance Code, children's health benefit plan ...............
___________________
__________________
__________________
___________________
10. Chapter 221, Texas Insurance Code
(a) Returned premiums .....................................................................................
___________________
__________________
__________________
___________________
(b) Dividends paid policyholders .......................................................................
___________________
__________________
__________________
___________________
11. Federal Crop Insurance Corporation (FCIC) multi-peril crop pre-emption .........
___________________
__________________
__________________
___________________
12. Chapter 2004, Texas Insurance Code, Property Protection Program
for Underserved Areas .......................................................................................
___________________
__________________
__________________
___________________
13. Health Group Cooperatives (Chapter 1501, Texas Insurance Code) .................
___________________
__________________
__________________
___________________
14. Total Non-taxable Premiums (Enter total here and on the appropriate
.00
.00
.00
.00
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)
See additional information on back.

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