Schedule 800ret - Attachment To Form 800 - 2015 Virginia Retaliatory Tax Report

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Schedule 800RET
2015 Virginia Retaliatory
*VA8RET115888*
Tax Report
Company Name
Federal Employer ID Number
NAIC/License #
Section A - Additions to Direct Premiums Written
Column A
Column B
Virginia Basis
Basis for State of
Domicile as of 12/31/15
(Enter State Abbreviation)
1. Insurance Premiums License Tax
Column A: Enter amount from Form 800, Line 9.
Column B: Attach documentation to support the computation...................
.00
.00
2. Annuity or Fire Marshall Tax (Premium) _____________________ .00 ...
.00
3. Workers’ Compensation Tax (Column A only) .........................................
.00
4. Company License or Certificate of Authority Fee ......................................
.00
5. Annual Corporation Registration Fee ........................................................
.00
.00
6. Annual Statement Filing/Abstract/Publication Fee ....................................
.00
7. Fee for Safekeeping Deposit .....................................................................
.00
.00
8. Corporation Permit Tax ..............................................................................
.00
9. Capital Stock Tax .......................................................................................
.00
10. Assessment for Maintenance of Bureau of Insurance ...............................
.00
.00
11. Fire Programs Fund Assessment ..............................................................
.00
.00
12. Flood Fund Assessment ............................................................................
.00
.00
13. HEAT Fund Assessment ............................................................................
.00
.00
14. Fraud Fund Assessment............................................................................
.00
.00
15. MCHIP Fund Assessment .........................................................................
.00
.00
16. Birth-Related Neurological Injury Fund Assessment (BIF) ........................
.00
.00
17. Municipal Average Gross Premium Tax
Kentucky: 1st Year Premium
__________________________.00 ...
Alabama: Renewal w/o change __________________________.00 ...
.00
18. Municipal Average Fixed Fees ..................................................................
.00
19. Agents’ Appointment Fees
Initial #
_______________________________________
Renewal #
_______________________________________ ........
.00
.00
20. Specify in detail other taxes/fees not listed above. ..................................
a.
.00
.00
b.
.00
.00
c.
.00
.00
21. TOTALS .....................................................................................................
.00
.00
22. RETALIATORY TAX DUE - Line 21, Column B minus Line 21, Column A
(but not less than zero). Enter on Form 800, Line 17. ...............................
.00
2616023 Rev 04/15
Attach completed Schedule 800RET to Form 800.

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