Form In-0578 - Statement Of Premiums And Fees For Taxation - Companies Other Than Life - Tennessee Department Of Commerce And Insurance - 2002 Page 4
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5FOR DEPARTMENT USE ONLY
121/972 ______________________________
131 _________________________________
STATE OF TENNESSEE
THE DEPARTMENT OF COMMERCE AND INSURANCE
880/300 ______________________________
P.O. BOX 198983
Nashville, TN 372198983
(615) 7411670
125 _________________________________
STATEMENT OF PREMIUMS AND FEES FOR TAXATION
Seq # __________
COMPANIES OTHER THAN LIFE
Posted by
Company Name
Contact Person
Due Dates:
Calendar Year
June 1
August 20
Address (No. & Street)
EMail Address
NAIC CO.CODE
December 1
City, State & Zip
Phone Number/ Fax Number
Date Admitted to TN
Domiciliary State
This Return Must Be Completed and Filed Even if There Were No Premiums Written
TAX IS BASED ON 25% OF ACTUAL PREMIUMS WRITTEN DURING THE ENTIRE
PREVIOUS YEAR OR AT LEAST 80% OF PREMIUMS WRITTEN DURING QUARTERLY
Premiums
Tax
FILING PERIOD OF CURRENT YEAR.
1. Premium Tax (
$
$
2.5% On taxable direct premiums other than Workmen’s Compensation)
2. Workmen’s Compensation Tax
$
$
(4% on Workmen’s Compensation Premiums)
3. Fire Marshal Tax
$
(as Computed in Schedule B)
4. Workmen’s Compensation Surcharge
$
(as Computed in Schedule E)
5. Total Premiums and Tax
$
$
* Do not list negative Tax amounts on any of the above lines; if negative, enter zero (0)
Make remittance payable to: TENNESSEE DEPT. OF COMMERCE & INSURANCE
Schedule B – COMPUTATION OF FIRE MARSHAL TAX
(To Be Computed By Property Insurers Only)
PERCENTAGE
DIRECT
FIRE
TO BE
LINE OF BUSINESS PREMIUMS
PORTION
APPLIED
Fire Lines
$
100%
$
Farm owners Multiple Peril
$
55%
$
Homeowners Multiple Peril
$
55%
$
Commercial Multiple Peril (nonliability portion & liability portion)
$
50%
$
Inland Marine
$
20%
$
Private Passenger Auto Physical Damage
$
8%
$
Commercial Auto Physical Damage
$
8%
$
Aircraft (All Perils)
$
8%
$
Industrial Fire
$
100%
$
Other
$
$
Fire Portion Subject to Fire Marshal Tax (Sum of the above fire portion lines)
$
0.0075
Apply ¾ of 1%
X
FIRE MARSHAL TAX
$
ENTER THIS AMOUNT
Do not list negative amounts on any of the above lines; if negative, enter zero (0)
ON LINE 3 ABOVE
1 OF 2
FORM IN0578 (Rev. 10/02)
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