Statement Of Premiums And Fees For Taxation (To Be Filed On Or Before March 1) Foreign Risk Retention Groups
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1
2
3
4FOR DEPARTMENT USE ONLY
CI375 121/974 ________________________
CI393 131 ___________________________
STATE OF TENNESSEE
CI359 880/300 ________________________
THE DEPARTMENT OF COMMERCE AND INSURANCE
P.O. BOX 198983
CI383 125 ___________________________
Nashville, TN 37219-8983
(615) 741-1670
CI735 122/981 ________________________
STATEMENT OF PREMIUMS AND FEES FOR TAXATION
(To Be Filed On Or Before March 1)
Posted by
FOREIGN RISK RETENTION GROUPS
Company Name
Contact Person
Amended
Address (No. & Street)
E-Mail Address
Calendar Year
NAIC CO.CODE
City, State & Zip
Phone Number/ Fax Number
Date Admitted to TN
Domiciliary State
Premiums
Tax
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.
Premiums, if any, required to balance with Schedule T
$
4.
Total premiums reported on Schedule T (Tennessee Business)
$
$150.00 MINIMUM TAX
5.
Total Tax (Sum of Lines 1 and 2)
If less than $150.00, Enter
$
6.
Fire Marshal Tax -- (as Computed in Schedule B)
$
7.
Workmen’s Compensation Surcharge -- (as Computed in Schedule E)
$
$
8.
Premium finance or service charges not included in above tax @ 2.5%
$
9.
Total premium, fire marshal, workmen's compensation surcharge and premium finance
or service charge taxes (Sum of line 5 thru 8)
*
Do not list negative tax amounts on any of the above lines; if negative, enter zero (0)
10. Amount of investment credit (Schedule C) or any prepayments, if applicable
$
Note: Do not take credit for prior year overpayments
$
$
11. Total Tax Due (Line 9 Minus Line 10)
$
12. Retaliatory Tax (As Computed in Schedule D)
$
13. TOTAL AMOUNT DUE (Sum of lines 11 and 12)
Please attach a copy of Tennessee business page from the Annual Statement.
Make remittance payable to: TENNESSEE DEPT. OF COMMERCE & INSURANCE
*
Explanation of Non-Taxable Premiums Required to Balance With Schedule T of Annual Statement.
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
FOR DEPARTMENT USE ONLY
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Audited By ___________________ Date ____ /____ /_______
Foreign Risk Retention Group Annual Form Rev 12/2009
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