Form 300 - Calendar Year 2014 Premium Tax Final For Life Companies

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CALENDAR YEAR 2014 PREMIUM TAX FINAL FOR LIFE COMPANIES

Office of Superintendent of Insurance, 1120 Paseo De Peralta, Santa Fe, NM 87501, P.O. Box 1689, Santa Fe, NM 87504-1689, Room 433

Make check payable to “Office of Superintendent of Insurance”

For calendar year ending December 31, 2014. Due April 15, 2015.

Late, unsigned and/or incomplete reports will be assessed a penalty pursuant to NMSA 1978, Section 59A-6-4.

Company Name: ______________________________________________

Company Co. #__________

Company Address:_____________________________________________

Class: __________

_____________________________________________

NAIC: __________

Contact: _______________________________________________

Phone/Email:____________________________________________

AMENDED,

Reason:________________________________

DEDUCTIONS ALLOWED:

Supporting Documents Required

1. Gross Premiums

2.Return

3.Political

4. Dividends

5. Premiums

6. Net Premiums on

received from

premiums

Subdivisions

paid/credited to

received from

which the New Mexico

CLASS

policies within the

policyholders

Authorized

tax is based.

State of New

companies for

Mexico

reinsurance on

NM risks.

(1) Ordinary Life

(2) Credit Life (GRP and

INDV)

(3) Group Insurance

(4) Industrial Insurance

(13) Aggregate write-ins for

other lines

(24) Group Accident and

Health

(24.2) Credit A&H (GRP and

Indv.)

(24.3) Collectively Renewable

A&H

(25.1) Non-Cancellable A&H

(25.2) Guaranteed Renewable

A&H

(25.3) Non-Renewable A&H

(25.4) Other Accident Only

(25.5) All other A&H

1.TOTALS

2. Tax Due (3.003% of line 1 )

3. Enter State of Domicile Tax Rate

4. If tax rate on line 3 is greater than 3.003% then enter Retaliatory Tax

Not presently being assessed per Order of OSI.

See DOI Bulletin 2009-008

5. Less Medical Insurance Pool (50% credit) Copies of cancelled check(s) to be submitted (if applicable)

6.1 Less Medical Insurance Pool (75% credit on special acts) Submit copies of Cancelled check(s) (if applicable)

7. Less Health Alliance (50% credit) Copies of cancelled check(s) to be submitted (if applicable)

8. Premium Tax Due

9. Less 1

and 2

quarterly taxes paid (include credit taken)

10. Less 3

and 4

quarterly taxes paid (include credit taken)

11. Less year 2013 remaining credit not used in line 9 & 10

12.Net Premium Taxes Due

#54

1. All Health Insurance Premiums on policies during the 2014 tax year

2. Surtax Due (1% of Line 1)

3. Less 1

and 2

surtax paid (include credit taken)

4. Less 3

and 4

surtax paid (include credit taken)

5. Less year 2013 remaining credit not used in line 3 & 4

7.Net Surtax Due (Do not net lines 12 and 7)

#53

Total Amount of Check

Check #

The signature for the Authorized Preparer means that: 1) The Authorized Preparer is authorized by the company’s Board of Directors to prepare this report. 2)

The Authorized Preparer has examined this report. 3) The contents of this report are true and correct to the best of the Authorized Preparer’s knowledge.

_____________________________

Notary Seal

President/Authorized Signature

Notary Signature __________________________

My Commission Expires ____________________

__________________________________

Secretary/Treasurer /Authorized Signature

Subscribed and sworn before me this ______ day of ________, 20___

Form 300

Postmarked _______

Initials

Updated: 12/12/2014