Form 25-102 - Annual Insurance Maintenance, Assessment And Retaliatory Report
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125-102
b.
PRINT FORM
RESET FORM
(Rev.1-10/16)
Texas Annual Insurance Maintenance, Assessment and Retaliatory Report
(For Licensed Insurance Companies and Miscellaneous Organizations)
A report must be filed even if no tax is due.
72100
a. T Code
e.
c.Taxpayer number
d. Filing period
f. Due date
Taxpayer name and report mailing address (Make any necessary name and report address changes below)
IMPORTANT
h.
g.
Blacken this box if your mailing address
has changed. Show changes
1.
beside the preprinted information.
i.
j.
Do not write in shaded areas
TYPE or PRINT
See instructions, Form 25-300
Form 25-300
COLUMN A
COLUMN C - AMOUNT DUE
* Taxable premiums are gross premiums minus dividends.
COLUMN B
TAXABLE PREMIUMS
(Multiply Column A by Column B)
TAX RATE
(Whole dollars only)
TAX RATES
* 1. Fire and allied
1a.
1c.
.00
(Ch. 252)
* 2. Casualty and fidelity
2a.
2c.
.00
(Ch. 253)
*
3. Motor vehicle
3a.
3c.
.00
(Ch. 254)
Texas Labor Code,
*
4. Workers' Compensation
4a.
4c.
.00
(Ch. 255 &
Sec. 407A.302 )
Texas Labor Code
*
5. DWC / OIEC
5a.
5c.
.00
(Secs. 403.002, 403.003, & 407A.301
)
Texas Labor Code
*
6. Workers' Compensation Research
6a.
6c.
.00
(
Sec. 405.003
)
7. Accident and health
7a.
7c.
.00
(Ch. 257)
8. Life and annuity
8a.
8c.
.00
(Ch. 257)
9. Local mutual aid association
9a.
9c.
.00
(Ch. 257)
10. Non-profit legal services corporation (Revenues)
10a.
10c.
.00
(Ch. 260)
11. Title company
11a.
11c.
.00
(Ch. 271)
12. TPA (Fees)
12a.
12c.
.00
(Ch. 259)
ENROLLEES
(Whole numbers)
13. HMO - basic health care service
13a.
13c.
(Ch. 258)
14. HMO - single health care service
14a.
14c.
(Ch. 258)
15. HMO - limited health care service
15a.
15c.
(Ch. 258)
POLICIES
(Whole numbers)
16. All lines of property and casualty policies
16a.
16c.
17. Accident and health policies/certificates of coverage
17a.
17c.
18. Life policies/certificates of coverage
18a.
18c.
19. HMO policies/certificates of coverage
19a.
19c.
20. Title policies
20a.
20c.
21. Long Term Care Facility Surcharge Fee
21a.
21c.
(Section 2203.351)
XXXXXXXXXXXXXX
22. Total amount
22.
(Total of Items 1c through 21c)
23. Annual Statement filing fee
23.
24. Retaliatory tax
24.
(From Form 25-200)
25. Total taxes and fees due
25.
(Total of Items 22 through 24)
You have certain rights under Chapters 552 and 559, Government Code, to review, request and correct
information we have on file about you. Contact us at the address or toll-free number listed on this form.
Form 25-102 (Rev.1-10/16)
* * * DO NOT DETACH * * *
26. Penalty and interest
26.
(See instructions)
27. TOTAL AMOUNT DUE AND PAYABLE
27.
(Total of Items 25 and 26)
Taxpayer name
k.
l.
T Code
Taxpayer number
Period
I declare the information in this document and all attachments is true and correct
to the best of my knowledge and belief.
Authorized agent
Preparer's name (Please print)
Make the amount in Item 27
Mail to: COMPTROLLER OF PUBLIC ACCOUNTS
payable to:
P.O. Box 149356
Daytime phone
Date
STATE COMPTROLLER
Austin, TX 78714-9356
(Area code & number)
For information about Insurance Tax,
call (800) 252-1387or (512) 463-4600.
Details are also available online at
111 A
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