Form 25-102 - Texas Annual Insurance Maintenance, Assessment And Retaliatory Report
Download a blank fillable Form 25-102 - Texas Annual Insurance Maintenance, Assessment And Retaliatory Report in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 25-102 - Texas Annual Insurance Maintenance, Assessment And Retaliatory Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
125-102
b.
b
(Rev.1-10/16)
PRINT FORM
RESET FORM
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.
a. T Code
72100
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
1.
has changed. Show changes
beside the preprinted information.
i.
j.
Do not write in shaded areas
TYPE or PRINT
See instructions, 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)
1a.
1c.
1. Fire and allied
(Ch. 252)
*
2a.
2c.
2. Casualty and fidelity
(Ch. 253)
*
3a.
3c.
3. Motor vehicle
(Ch. 254)
*
Texas Labor Code,
4a.
4c.
4. Workers' Compensation
(Ch. 255 &
Sec. 407A.302
)
*
Texas Labor Code
5a.
5c.
5. DWC / OIEC
(
Secs. 403.002, 403.003, & 407A.301
)
*
Texas Labor Code
6a.
6c.
6. Workers' Compensation Research
(
Sec. 405.003
)
*
7a.
7c.
7. Accident and health
(Ch. 257)
8a.
8c.
8. Life and annuity
(Ch. 257)
9a.
9c.
9. Local mutual aid association
(Ch. 257)
10a.
10c.
10. Non-profit legal services corporation (Revenues)
(Ch. 260)
11a.
11c.
11. Title company
(Ch. 271)
12a.
12c.
12. TPA (Fees)
(Ch. 259)
ENROLLEES
(Whole numbers)
13a.
13c.
13. HMO - basic health care service
(Ch. 258)
14a.
14. HMO - single health care service
14c.
(Ch. 258)
15a.
15. HMO - limited health care service
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)
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.
111 A
Details are also available online at
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial