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25-103 b. PRINT FORM RESET FORM
(Rev.12-18/29)
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CD
a. T Code 71140
c. Taxpayer number d. Filing period e. f. Due date
You have certain rights under Chapters 552 and 559, Government Code,
to review, request and correct information we have on file about you.
SELECT FILING PERIODb Contact us at the address or phone number listed on this form.
(Independently Procured Insurance)Taxpayer name and tax report mailing address Type or print.(Make necessary name and address changes below.)
g. h. IMPORTANT
Blacken this box if your mailing address
Texas Annual Insurance Tax Report has changed. Show changes beside the 1
preprinted information.
b I
For Comptroller use only
i.PM j.FM k.NO Sch
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b b*2510300W121829*
The Non-Admitted and Reinsurance Reform Act (NRRA) passed as part of the Dodd-Frank Wall Street Reform and Consumer Protection
Act in 2010. Texas laws that relate to independently procured insurance were revised to comply with the provisions of the NRRA that
became effective on July 21, 2011. The federal law defines independently procured insurance as insurance procured directly by an Rb
insured from a nonadmitted insurer and provides that the home state of the insured controls for purposes of regulation and taxation. The
law also encourages the states to join a tax compact or agreement that would allow for the sharing of taxes due on policies that cover
Important Information Regarding Independently Procured Insurancerisks in multiple states. Texas has not joined any compact or agreement at this time; however, if Texas joins a compact in the future, b bb
additional information will be provided.
Who Must File: An insured whose home state is Texas and who procures insurance directly from a nonadmitted insurer, without an
agent's involvement , is liable for the independently procured tax on the policy.
Insureds whose policies were obtained through surplus lines agents/agencies, and who are no longer subject to this tax, should contact
the Comptroller's office at 1-800-252-1387 to discuss whether their account can be closed.
Refer to Publication 98-376, "Tax on Independently Procured Insurance," at www.comptroller.texas.gov/taxes/publications/98-376.pdf and
to the instructions on the reverse side of this form for additional information.
1. Total premiums allocated to Texas (net of return premiums) from all supplements
(Form 25-122)
1. .00
Your report cannot be processed without the supplement (Form 25-122).
Premium Tax Calculation
2. Premium tax rate I 2. .0485
("Premium" includes any premiums, membership fees, dues or
other consideration for insurance.) (Whole dollars only)
3. Total tax due 3.
b
Form 25-103 (Rev.12-18/29)
b
(Multiply Item 1 by Item 2)
4. Penalty and interest due 4. .
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* * * Return this entire form.* * *
5. TOTAL AMOUNT DUE AND PAYABLE 5.
Taxpayer name
l. m.
(See instructions.)
T Code Taxpayer number Period I declare that the information in this document and all attachments is true and..correct
(Item 3 plus Item 4)to the best of my knowledge and belief.
71020 Authorized agent
Preparer's name (Type or print.) b
Make the amount in Item 5 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 1-800-252-1387. 111b A
b b bDetails are also available online at www.comptroller.texas.gov.
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