PDF document

- 1 -

AB 25-103 b. PRINT FORM RESET FORM
CD (Rev.12-18/29) b *2510300W121829*

Texas Annual Insurance Tax Report
(Independently Procured Insurance) You have certain rights under Chapters 552 and 559, Government Code,
to review, request and correct information we have on file about you.
a. T Code b 71140 I Type or print. Contact us at the address or phone number listed on this form.
c. Taxpayer number d. Filing period e. f. Due date
b b
Taxpayer name and tax report mailing address (Make necessary name and address changes below.)
g. h. IMPORTANT
Blacken this box if your mailing address
has changed. Show changes beside the 1
preprinted information. Rb
For Comptroller use only
i.PM j.FM k.NO Sch
1
b b b
Important Information Regarding Independently Procured Insurance
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
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
risks in multiple states. Texas has not joined any compact or agreement at this time; however, if Texas joins a compact in the future,
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.

Premium Tax Calculation I Your report cannot be processed without the supplement (Form 25-122).

1. Total premiums allocated to Texas (net of return premiums) from all supplements
(Form 25-122) ("Premium" includes any premiums, membership fees, dues or
other consideration for insurance.) (Whole dollars only) 1. b .00

2. Premium tax rate 2. b .0485

3. Total tax due (Multiply Item 1 by Item 2) 3. b .

Form 25-103 (Rev.12-18/29) * * * Return this entire form.* * *

4. Penalty and interest due (See instructions.) 4. .

5. TOTAL AMOUNT DUE AND PAYABLE (Item 3 plus Item 4) 5. b .

Taxpayer name
l. m.
b
bT Code bTaxpayer number b Period I declare that the information in this document and all attachments is true and correct
to the best of my knowledge and belief.
71020 Authorized agent
AB
Preparer's name (Type or print.)
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.
Details are also available online at www.comptroller.texas.gov.
111 A

- 2 -

Enlarge image

Form 25-103 (Back)(Rev.12-18/29)

            Instructions for Completing the Texas Annual Insurance Tax Report
                                              (Independently Procured Insurance)
When to File
The report and payment are due once a year, on or before May 15, following the calendar year in which the insurance was procured, continued
or renewed.
General Instructions
I If any preprinted information is not correct, mark out the item and write in the correct information.
I Complete the Texas Annual Insurance Tax Report - Supplement (Form 25-122).
I Item c. Taxpayer Number: If the insured files a report for other taxes administered by this agency, please enter that 11-digit number in this box. If a 
  taxpayer number has not been established for the insured by this agency and the insured is an individual, enter the insured's Social Security 
  number in Item c. Other entities should enter the Federal Employer Identification Number (FEIN) assigned to their organization. 
FEDERAL PRIVACY ACT.  Disclosure of your Social Security number is required and authorized under law for the purpose  of tax administration 
and  identification  of  any  individual  affected  by  applicable  law  [42  U.S.C., Section  405(c)(2)(C)(i);  Texas  Government  Code,  sections  403.011, 
403.015, and 403.078].  Release of information on this form in response to a public information request will be governed by the Public Information 
Act, Chapter 552, Government Code. 
Exemptions and Preemptions
  See Publication 94-142, "Surplus Lines Tax Exemptions/Preemptions," at www.comptroller.texas.gov/taxes/publications/94-142.pdf.
  Exempt premiums are premiums for an independently  procured insurance policy that covers risks or exposures  that are properly allocated to 
  federal waters, international waters or risks or exposures that are under the jurisdiction of a foreign government. 
  This tax does not apply to an individual life or individual disability policy.
  Federal preemptions to state taxation for independently procured insurance include premiums for policies that are issued to the following entities:
  I the Federal Deposit Insurance  Corporation (FDIC), when it acts as the receiver of a failed financial institution that holds the property being
    insured;
  I the National Credit Union Administration;                                                          Electronic reporting and payment options 
  I a federally chartered credit union; and                                                            are available 24 hours a day, 7 days a week.
  I Indian Tribal Nations                                                                              Have this form available when you log on.
                                                                                                       www.comptroller.texas.gov/taxes/file-pay/
The home state is defined by the NRRA as:
  (A) IN GENERAL. - Except as provided in subparagraph (B), the term "home state" means, with respect to an insured
        (i) the state in which an insured maintains its principal place of business or, in the case of an individual, the individual's principal residence; or
        (ii) if 100% of the insured risk is located out of the state referred to in clause (i), the state to which the greatest percentage of the 
        insured's taxable premium for that insurance contract is allocated.
  (B) AFFILIATED GROUPS. - If more than one insured from an affiliated group are named insureds on a single nonadmitted insurance contract, 
  the term "home state" means the home state, as determined  pursuant  to subparagraph  (A), of the member of the affiliated group that has the 
  largest percentage of premium attributed to it under such insurance contract.
Specific Instructions
Item 1 - Determining Texas Premiums: For new or renewal policies procured directly from a nonadmitted insurer that were effective on or after 
July 21, 2011, when Texas is the home state of the insured:
                                                                                I 100% of the tax is due Texas on a policy that covers risks in Texas
                                                                                  only.
                                                                                I 100% of the tax is due Texas on a policy that covers risks in more
                                                                                  than one state. 
                                                                                I If Texas is the home state of the insured but the policy covers risks 
                                                                                  that are 100% located outside of Texas, then the state to which the 
                                                                                  greatest percentage of the premium is allocated becomes the home 
                                                                                  state. The policy would then be subject to regulation and taxation by 
                                                                                  that home state and not by the state of Texas.
                                                                                Endorsements  and  audits  on  independently  procured  policies  are 
                                                                                subject  to  the  laws  that  apply  to  the  original  policy;  however,  they 
                                                                                should be reported for the tax year in which the endorsement or audit
occurs. Using the original policy's effective date may result in the application of penalty and/or interest for late filing. The tax for endorsements and 
audits that generate return premiums due a policyholder must be calculated using the same tax rate that was originally charged.  
Item 4 - Penalty and Interest: If tax is paid 1-30 days late, enter 5% of the amount in Item 3. If tax is paid 31-60 days late, enter 10% of the amount 
in Item 3. If tax is paid more than 60 days late, enter 10% penalty PLUS interest on the amount in Item 3. Calculate interest at the rate published 
online at www.comptroller.texas.gov/taxes/file-pay/interest.php or call the Comptroller's office at 1-877-447-2834 for the applicable interest rate.   
Item 5 - Total Amount Due and Payable: The total amount due and payable can be paid by the insured or by another party designated  by the 
insured.

PDF file checksum: 681126562

(Plugin #1/9.12/13.0)