Form 801 - Virginia Surplus Lines Brokers Quarterly Tax Report

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FORM 801
VIRGINIA SURPLUS LINES BROKERS
QUARTERLY TAX REPORT
Lines Broker’s Annual Reconciliation Tax Report, Form 802, must
NEW FOR 2013
be filed by March 1 following the close of the taxable year, even if
Effective for taxable years beginning on and after January 1,
no insurance premiums license tax is owed. Refer to Form 802 for
2013, the administration of the insurance premiums license tax
further information.
has been transferred from the Virginia Bureau of Insurance (BOI)
to the Department of Taxation (the Department). Responsibilities
Where To File and Pay: You can file and pay online with eForms
transferred to the Department include the processing of tax returns;
at For paper filing, file the report with the
handling of related payments and billing; customer service functions;
Virginia Department of Taxation, PO Box 26179, Richmond, VA
and all insurance premiums license tax collections and auditing
23260-6179. The report must be accompanied by a check or money
duties.
order for the amount due made payable to the Virginia Department
of Taxation.
The BOI will continue to be responsible for the licensing of surplus
When To File and Pay: The report and payment must be postmarked
lines brokers. In the event that a taxpayer fails to pay its insurance
no later than thirty calendar days after the end of each calendar
premiums license tax, the BOI will be permitted to suspend or revoke
quarter. Payments are considered timely filed if filed electronically
the broker’s license upon notification from the Department. The BOI
or postmarked on or before midnight of the due date. If the due
will continue to administer the annual maintenance fund assessment.
date falls on a Saturday, Sunday or legal holiday, the report must
GENERAL INFORMATION
be postmarked on or before the next business day.
The Department’s website, , has information
LINE INSTRUCTIONS
to help you with your tax filing responsibilities. If you cannot find
what you are looking for, try our Live Chat feature. A representative
Line 1 - Gross Premiums: Enter the gross amount of all premiums,
is available online to assist you.
assessments, dues and fees collected, received or derived or
eForms: File and pay your tax online for free. Simply complete
obligations taken during the quarter from policies for insureds
the online version of the paper estimated report by entering the
whose home state is the Commonwealth of Virginia.
tax information as you would if you were completing a paper form.
Line 2 - Additional Premiums: Enter the amount of premiums
e-Subscriptions: With our free e-Subscriptions service, we’ll send
written during the quarter for additional insurance coverage for
you e-mails on topics you select. You can even get reminders
insureds whose home state is the Commonwealth of Virginia as a
about upcoming return due dates. Sign up today on our website!
result of an insurance rider, rate adjustment or advance premium
less than actual premium.
Forms Online: Virginia tax forms are available for download.
Line 4 - Returned Premiums: Enter the portion of premiums
Secure E-mail: Use our iFile Secure Message Center.
returned to an insured whose home state is the Commonwealth of
Other Inquiries: Call 804-367-8037 or write to the Virginia
Virginia during the quarter as a result of an insurance rider, policy
Department of Taxation, PO Box 26179, Richmond, VA 23260-6179.
cancellation, rate adjustment or an excess of advance premium
Do not mail returns to this address.
over actual premium.
INSTRUCTIONS
Line 7 - Credits from Prior Periods: Enter the portion of premiums
Filing Requirements: A surplus lines broker must file this quarterly
returned to an insured whose home state is the Commonwealth of
report, Form 801, if its annual premiums tax liability can reasonably
Virginia during the quarter as a result of an insurance rider, policy
be expected to exceed $1,500 and, during the quarter, it derived
cancellation, rate adjustment or an excess of advance premium
direct gross premium income from policies for insureds whose home
over actual premium on which tax has already been paid in a
state is the Commonwealth of Virginia. However, if the amount on
prior quarter of this taxable year. If the amount on Line 7 equals
Line 8 is $0, Form 801 is not required to be filed for that quarter.
or exceeds the amount on Line 6, do not file Form 801. Carry the
Quarterly tax reports must be dated and signed by the surplus
excess forward to your next quarterly report. Refunds are only
lines broker or an agency officer. In addition, the Virginia Surplus
issued on the annual return, Form 802.
Detach at dotted line below. DO NOT SEND ENTIRE PAGE
Form 801
Virginia Surplus Lines Brokers Quarterly Tax Report
(Doc ID 801)
Office Use
For Period Ending
Due Date
/
/
. . . . . . . . . . . . . . . . .
1.
1. Gross Premiums
00
0000000000000000 8018888 000000
. . . . . . . . . . . . . .
2.
2. Additional Premiums
00
. . . .
3.
3. Total Premiums (Line 1 plus Line 2)
00
Account Number (Enter FEIN Below - Required)
Broker License Number
39- ___ ___ ___ ___ ___ ___ ___ ___ ___ F001
. . . . . . . . . . . . . .
4.
00
4. Returned Premiums
Name of Surplus Lines Broker
5. Taxable Premiums (Line 3 minus Line 4)
00
5.
Address
.
6. Premiums Tax (Multiply Line 5 by 2.25%)
6.
00
City, State and ZIP
. . . . . . . . . . .
7. Credits from Prior Periods
7.
00
Total Amount Due
8.
I declare that this report (including accompanying schedules and statements) has been examined
(Line 6 minus Line 7)
.
00
8.
by me and to the best of my knowledge and belief is true, correct and complete.
Surplus Lines Broker/Agency Officer Signature
Date
Phone Number
VA DEPT OF TAXATION 2616010 REV. 02/14

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