Form Ig255 - Nonadmitted Insurance Premium Tax Return For Direct Procured Insurance - 2012

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IG255

2012 Nonadmitted Insurance Premium Tax Return for Direct Procured Insurance

Due March 1, 2013

Check if:

Amended return

No activity

Name of insured

Check if new address

Minnesota tax ID (required)

Contact person

Mailing address

Daytime phone

Fax number

City

State

Zip code

Email address

Website address

I am licensed to obtain insurance from nonadmitted insurers

Check if you are a purchasing group

from

1 Total gross premiums paid (from page 2, Column G) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Total return premiums received (from page 2, Column H) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 Taxable gross premiums paid (subtract line 2 from line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

.02

4 Tax rate is 2% (0 .02) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

5 Total gross premiums tax due (multiply line 3 by line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

6 Penalty (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

7 Interest (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

8 TOTAL AMOUNT DUE (or overpaid) (add lines 5 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

If you owe additional tax:

Payment method:

Electronic payment

Check

(payable to Minnesota Revenue; write MN tax ID number on check; attach PV58)

Enter amount paid

Date paid

(If amount paid is different from amount due on line 8, attach an explanation.)