Nevada Department of Taxation
Due Date
Taxpayer ID No:
______________
1550 College Parkway Ste 115
Federal ID: ______________________
March 15, 2013
Carson City, NV 89706
Premium Tax: ______________________
Phone: (775) 684-2000
Retaliatory Tax: ______________________
Fax: (775) 684-2020
Total Remittance: ______________________
ANNUAL INDUSTRIAL INSURANCE (WORKERS COMPENSATION)
PREMIUM TAX RETURN 2012
Department Use Only
Amount: _____________________________
Check No: _____________________________
Date Rec’d: _____________________________
Initials: _____________________________
Net Quarterly Taxable Premiums/Considerations
1. Total Industrial Insurance Premiums - Must agree with Schedule 1, Line 3A
1.
2. Gross Industrial Insurance Premium Tax (3.5% of Line 1 – Must agree with Schedule 1, Line 4 A)
2.
3. Industrial Insurance Credit (Division of Industrial Relations) (NRS 680B.036)
3.
A. Subtotal (Line 2 minus Line 3)
A.
4a.
4a.
Home Office Credit, if qualified (NRS 680B.050) 50% or .5 of Line 4 (Form PT-04 and required documents must be attached)
4b. Amount of Ad Valorem Taxes Paid, if qualified for Home Office Credit (NRS 680B.050)
4b.
4c. Max Credit Allowed
4c.
4d. Allowable Home Office Credits
4d.
5. Subtotal of Net Industrial Insurance Premium Tax Due (Line A minus Line 4d)
5.
6. Property/Casualty Guaranty Association Credit (NRS 687A)
6.
B. Total Overpayments applied from previous years
B.
C. Total Overpayments refunded by Nevada in 2011
C.
7. Net Industrial Insurance Premium Tax Due (Line 5 minus Lines 6 and B, Plus Line C)
7.
8. Penalty ( See Instructions for rate)
8.
9. Daily Interest. Premium Tax Due (Line 7) multiplied by .00049315068 times the number of days late
9.
10. Total Industrial Insurance Premium Tax Due (Line 7 plus Lines 8 and 9)
10.
If Line 10 results in an overpayment, the overpayment may be refunded.
Amount to be refunded
NRS REQUIRES THIS RETURN MUST BE SIGNED
I hereby declare under penalty of perjury that this premium tax report (including any accompanying schedules and statements) has been
examined by me and is true, correct and complete report.
Signature of Taxpayer or Authorized Agent
Printed Name of Taxpayer or Authorized Agent
Date
Telephone
IIP-A
Revised 11-22-11