Form R-1a - Initial Declaration Of Estimated Insurance Premiums License Tax Page 2
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1
2Form R-1A
VIRGINIA DEPARTMENT OF TAXATION
INITIAL DECLARATION OF ESTIMATED INSURANCE PREMIUMS LICENSE TAX
Go online and use i-Reg…it is faster and easier than completing this form!
Use this form to make an initial declaration of your estimated insurance premiums license tax. Submit this form with your
Business Registration Application (Form R-1).
Federal Employer Identification Number
Business Name (Full legal name of the business)
Physical Street Address
NAIC Number (5-digit code)
City or Town
State
ZIP Code
Column A Column B Column C
DECLARATION OF ESTIMATED INSURANCE
Estimated Direct Gross
Rate
Initial Insurance
PREMIUMS LICENSE TAX WORKSHEET
Premiums Income
Premiums License Tax
LIFE & ACCIDENT and HEALTH INSURANCE COMPANIES:
1. Life
$
X
2.25%
=
$
2. Disability & Double Indemnity
$
X
2.25%
=
$
3. Accident & Sickness
$
X
2.25%
=
$
4. Industrial Sick Benefit
$
X
1.00%
=
$
5. TOTAL
$
$
6. FIRE, CASUALTY, and TITLE INSURANCE COMPANIES:
All lines of insurance, excluding workers’ compensation premium
and, as applicable to mutual insurers, dividends to policyholders.
$
X
2.25%
=
$
Check here if: Declaration of estimated direct gross premium income is $0.00 for the remainder of the calendar year.
I declare that this declaration has been examined by me and, to the best of my knowledge and belief, it is true, correct, and complete.
Signature
Date
Phone
Do Not Separate Voucher - Send Entire Form
Virginia Insurance Premiums License Tax
Form 800IES
Voucher 1
Declaration of Estimated Insurance Premiums License Tax
(DOC ID 800ES)
Payment Voucher
Virginia Department of Taxation
If payment made electronically,
PO Box 1114, Richmond, VA 23218-1114
do not file this voucher.
(804) 367-8037
Office Use
Check
Money Order
/
/
0000000000000000 8008888 000000 01
39-
For Office Use
1. Taxable Year ......
Federal Employer Identification Number
NAIC/License #
2. Total estimated
Company Name
direct gross pre-
miums for year .. $
Address (Number and Street)
3. Estimated tax
for the year ...... $
v
City, State and ZIP Code
— Do not write below this line. —
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Parent category: Financial