Form 302 2015 - Property Final

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NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE FINANCIAL AUDIT BUREAU
Mailing Address: P.O. Box 1689 Room 433, Santa Fe, NM 87504-1689 Physical Address: 1120 Paseo De Peralta Room 433, Santa Fe, NM 87501
CALENDAR YEAR 2015 PREMIUM TAX FINAL FOR PROPERTY COMPANIES
F
or calendar year ending December 31, 2015.
This form serves as notice that this premium tax filing and related payment is due April 15, 2016
Company Name: _________________________________________________
NM Co. #: __________
Company Address: _________________________________________________
Class: __________
_________________________________________________
NAIC: __________
Contact: __________________________________
Phone: __________________________________
AMENDED,
:_________________________
Reason
Email:
Name or address change (Submit address change form)
________________________________________
Late, unsigned and/or INCOMPLETE reports will be
COLUMN
DEDUCTIONS
assessed a penalty pursuant to § 59A-6-4, NMSA 1978
TOTAL
OSI Bulletin 2015-002
(Column 1 minus
Make check payable to:
SUPPORTING DOCUMENTS REQUIRED
column 2 & 3)
“Office of Superintendent of Insurance”
1.Premiums
2.Political Subdivisions
6. Net Premiums on
3.Federally Exempt
written from
which the New
(MUST ATTACH
Premiums (MUST be
policies within
CLASS
Mexico premium
BREAKDOWN or form will
reflected on the NM
the State of New
tax is
be considered incomplete)
Business Page)
Mexico as per NM State
based.
Business page
(1)
Fire
(2.1) Allied Lines Crop- Crop
Hail
(2.2) Multiple Peril Crop
(2.3) Federal Flood
(2.4) Private Crop
(3) Farm owners Multiple Peril
(4) Homeowners Multiple Peril
(5.1) Commercial Multiple Peril
(non-liability portion)
(5.2) Commercial Multiple Peril
(liability portion)
(8) Ocean Marine
(9) Inland Marine
(12) Earthquake
Miscellaneous or Service Fees
1. TOTALS
2. Premium Tax Due (3.003% of Line 1, Column 6)
Retaliatory Tax is not presently being assessed per Order of OSI. See DOI
Bulletin 2009-008
st
nd
3. Less 1
and 2
2015 quarterly taxes paid (include credit taken)
rd
th
4. Less 3
and 4
2015 quarterly taxes paid (include credit taken)
5. Less year 2014 remaining credit not used in line 3 & 4
#78
6. Net Premium Tax Due
Total Amount of Check
Check #
I declare under penalty of perjury as representative(s) of the insurance company named above I have examined this return and
accompanying schedules and statements and to the best of knowledge and belief they are true and correct and complete.
NOTARY SEAL
_________________________________
Secretary/Treasurer Authorized Signature
Notary Signature ________________________
My Commission Expires __________________
_________________________________
Subscribed and sworn before me this ________ day of __________, 20___
President Authorized Signature
NOTE: If this report is not signed by the officers of the company specifically named by title above, a signed and notarized jurat must be attached.
Form 302: 2015 Property Final Updated March 1, 2016
Postmarked _______Initials
_________

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