Looking for a Tennessee Department Of Revenue Forms And Templates? Download it for free!

Schedule E – WORKMEN'S COMPENSATION INSURANCE SURCHARGE

(To Be Completed By All Companies Writing Workmen’s Compensation Insurance)

Complete steps 1 thru 5. If Company did not write any Workmen’s Compensation premiums during prior calendar quarter,

please indicate as “NONE” on Line 1 of this Schedule.

1. Gross Workmen's Compensation Premiums as listed on Line 2, Page 1

*2. Subtract Premiums not subject to Surcharge (see note below)

3. Premiums subject to Workmen’s Compensation Surcharge

4. Apply fourtenths of one percent (0.4%) rate to amount on line 3

0.004

5. WORKMEN’S COMPENSATION SURCHARGE

ENTER THIS AMOUNT ON

Do not list a negative Surcharge amount on line 5; if negative, enter zero (0)

LINE 4, PAGE 1.

NOTES

*The Surcharge of fourtenths of one percent (0.4%) on Workmen’s Compensation Insurance shall not apply to any premiums written on or for an

employer who employs ten (10) or less employees unless such employer is in the business of construction or manufacturing.

Explain in detail the method used in calculating any reduction of Workmen’s Compensation Surcharge premiums which are not subject to the

Surcharge tax in the space below:

STATEMENT OF PREMIUMS AND FEES FOR TAXATION MUST OBTAIN ORIGINAL SIGNATURE AND NOTARY

STATE OF ________________________________ COUNTY OF ____________________________

I, _______________________________________________ , do hereby make oath that I am _____________________________________

(Officer’s Name)

(Official Title)

of the _______________________________________________________________________________________________________________

and that the foregoing Statement of Premiums and Fees for Taxation is true to the best of my knowledge, information and belief.

_____________________________

Signature of Officer

___________________________________

Notary Public

(SEAL)

Subscribed and Sworn before me ______________________

Date

My commission expires ______________________

Date

TENNESSEE STATUTES APPLICABLE TO PREMIUM TAXES

LINE 1 Tax on Premiums _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Tenn. Code Ann. § 564204

Tenn. Code Ann. § 564205

LINE 2 Tax on Workmen’s Compensation Premiums _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Tenn. Code Ann. § 564206

LINE 3 Additional tax on fire Insurance _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Tenn. Code Ann. § 564208

LINE 4 Workmen’s Compensation Surcharge _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Tenn. Code Ann. § 564206

FAILURE TO FILE TAX RETURN Within Time Prescribed _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Tenn. Code Ann. § 564216

2 OF 2

Audited By_________________

FORM IN0578 (Rev. 10/02)

Form In-0578 - Statement Of Premiums And Fees For Taxation - Companies Other Than Life - Tennessee Department Of Commerce And Insurance - 2002 Page 5

Related Articles

Related forms

Related Categories