Form 25-104 - Texas Annual Insurance Tax Report - Surplus Lines/purchasing Groups
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25-104
b
b.
(Rev.2-17/25)
Texas Annual Insurance Tax Report
A report must be filed even if no tax is due.
Surplus Lines / Purchasing Groups
b
under Chapters 552 and 559, Government Code, to review, request and correct
You have certain rights
71120
a. T Code
information we have on file about you. Contact us at the address or phone number listed on this form.
c. Taxpayer number
d. Filing period
f. Due date
e.
b
b
Taxpayer name and tax report mailing address (Make necessary name and address changes below)
IMPORTANT
g.
h.
Blacken this box if your mailing
address has changed. Show changes
1.
R b
beside the preprinted information.
i.
j.
b
b
Total surplus lines business as agent of record (Whole dollars only)
SECTION I -
(reported to the Surplus Lines Stamping Office of Texas (SLSOT))
b
.00
A. Texas premiums
A.
yet
(not
reported to the SLSOT)
b
B. Texas premiums
B.
.00
(reported to or subject to SLSOT reporting)
b
C. Non-taxable premiums
C.
.00
(reported to or subject to SLSOT reporting)
b
D. Other states' premiums
D.
.00
(See instructions.)
Not subject to SLSOT reporting
b
E. Non-taxable premiums
E.
.00
b
F. Other states' premiums
F.
.00
b
(Total of Items A - F)
$
.00
Total premium as agent of record
G.
(See instructions.)
SECTION II - Tax Base Election
b
1
b
2
Premium-written basis
Premium-received basis
Surplus lines agents must complete this section using the tax base election option selected.
SECTION III -
The premiums reported in this section will not necessarily match the premiums shown in SECTION I. SECTION III premiums should reflect the premiums subject to tax
on
the basis of taxation method selected, i.e., premium-received or premium-written.
(Whole dollars only)
b
1. Texas premiums
1.
.00
(Do not enter as a negative number.)
b
2. Texas returned premiums
2.
.00
(Item 1 minus Item 2)
b
3. Taxable premiums
3.
.00
.0485
(Multiply Item 3 by
) (Dollars and cents)
b
4. Premium tax due
4.
Purchasing groups and surplus lines agents writing purchasing group business must complete this section.
SECTION IV -
b
(Whole dollars only)
5. Texas premiums
5.
.00
b
(Do not enter as a negative number.)
6. Texas returned premiums
6.
.00
b
(Item 5 minus Item 6)
7. Taxable premiums
7.
.00
b
.0485
(Multiply Item 7 by
) (Dollars and cents)
8. Premium tax due
8.
b
(Item 4 plus Item 8)
9. Total taxes due
9.
10. Prepayment amount
10.
(Item 9 minus Item 10)
11. Total amount due
11.
* * * Do not detach. * * *
Form 25-104 (Rev.2-17/25)
(See instructions.)
.
12. Penalty and interest
12.
b
(Item 11 plus Item 12)
.
13. TOTAL AMOUNT DUE AND PAYABLE
13.
Taxpayer name
AB
b
k.
l.
b
b
b
T Code
Taxpayer number
Period
I declare that 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 (Type or print.)
Make the amount in Item 13
Mail to COMPTROLLER OF PUBLIC ACCOUNTS
payable to
P.O. Box 149356
Date
Daytime phone
STATE COMPTROLLER
Austin, TX 78714-9356
(Area code & number)
For information about Insurance Tax, call 1-800-252-1387 .
111 A
Details are also available online at
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