Form IB-43 "Gross Premiums Tax Return - Self-insured Workers' Compensation Corporation" - North Carolina

What Is Form IB-43?

This is a legal form that was released by the North Carolina Department of Revenue - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2020;
  • The latest edition provided by the North Carolina Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form IB-43 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Revenue.

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Download Form IB-43 "Gross Premiums Tax Return - Self-insured Workers' Compensation Corporation" - North Carolina

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CAROLINA
DEPARTMENT
OF REVENUE
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..............
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m
u:
==
=
===
=
Do Not Include This Page
·-·
N C
D(i)
R
-
I
•• · ··=!!! ::: ! : •
NORTH
::::
.
CAROLINA
DEPARTMENT
OF REVENUE
Instructions
For Handwritten
Forms
Before
Guidelines
Sending
Printing
Do not use red ink.
ocopies of returns.
Use blue or black ink.
Submit originals only.
,,___(8)
®
Do not mix form types.
Do not use dollar
Set page scaling to
signs, commas, or
"none." The Auto-Rotate
other punctuation
and Center checkbox
marks.
should be unchecked.
,
t®I
1�
1
Do not select "print on
c;
both sides of paper."
;
1
IB-43
Gross Premiums Tax Return
Web
Self-Insured Workers’ Compensation Corporation
1-21
DOR Use Only
For tax year beginning
and ending
(MM-DD-YY)
(MM-DD-YY)
Legal Name (First 35 Characters)
(USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
Mailing Address
City
State
Zip Code
Federal Employer ID Number
Name of Contact Person
Phone Number
State of Domicile
Fill in circle if applicable:
Payment has been made through electronic funds transfer (EFT)
Amended Return
If Company Ceased to be Self-Insured in North Carolina During the Year Enter Effective Date
Part 1.
Computation of Gross Premiums Tax
,
,
,
.
1. Adjusted Taxable Premiums (From Part 5)
00
1.
,
,
,
.
2. Gross Premiums Tax
2.
00
Multiply Line 1 by 2.5%
3. Tax Credits
,
,
,
.
a. Guaranty Fund (Credit cannot exceed tax amount on Line 2. Attach 2020 Guaranty
3a.
00
Assessment Tax Credit Available notice in support of credit claimed.)
,
,
,
.
b. CD-425 and NC-478 Tax Credits (Attach applicable forms)
3b.
00
,
,
,
.
4. Gross Premiums Tax Liability
4.
00
Line 2 minus Line 3a and 3b, but not less than zero
,
,
,
.
5. Prior Year Credit Applied to 2020
5.
00
(From Part 4, Line 1, Column 1)
,
,
,
.
6. Gross Premiums Tax Installment Payments
6.
00
(From Part 4, Line 5, Column 1)
,
,
,
.
7. Balance of Gross Premiums Tax Due
$
7.
00
Line 4 minus Lines 5 and 6, but not less than zero. If less than zero, enter amount on Line 10.
,
,
.
.
(See www.ncdor.gov for current
8. a. Penalties
b. Interest
00
00
interest rate and penalty information)
,
,
,
.
$
00
9.
9. Total Gross Premiums Tax Due
Add Lines 7, 8a and 8b
,
,
,
.
10.
10. Overpayment
00
,
,
,
.
11. Amount of Line 10 to be Applied to 2021 Gross Premiums Tax
11.
00
,
,
,
.
12. Gross Premiums Tax to be Refunded
12.
00
Line 10 minus Line 11
Printed Name:
Title:
Signature:
Date:
I certify that, to the best of my knowledge, this return is accurate and complete.
Returns are due by the 15th day of the 3rd month following the end of the calendar year. Your check or money
order must be in the form of U.S. currency from a domestic bank. Electronic filing of returns is not available.
N.C. Department of Revenue, Insurance Premiums Tax Unit, P.O. Box 25000, Raleigh, NC 27640-0300
Legal Name
FEIN
Page 2, Form IB-43, Web, 1-21
Part 2.
Computation of Insurance Regulatory Charge
,
,
,
.
13. Gross Premiums Tax Liability
00
13.
(From Part 1, Line 2)
,
,
,
.
14. Insurance Regulatory Charge
$
14.
00
Multiply Line 13 by 6.5%
,
,
,
.
15. Prior Year Credit Applied to 2020
15.
00
(From Part 4, Line 1, Column 2)
,
,
,
.
16. Insurance Regulatory Charge Installment Payments
16.
00
(From Part 4, Line 5, Column 2)
,
,
,
.
17. Balance of Insurance Regulatory Charge Due
$
17.
00
Line 14 minus Lines 15 and 16, but not less than zero. If less than zero, enter amount on Line 20.
,
,
.
.
(See www.ncdor.gov for current
18. a. Penalties
b. Interest
00
00
interest rate and penalty information)
,
,
,
.
$
19. Total Insurance Regulatory Charge Due
00
19.
Add Lines 17, 18a and 18b
,
,
,
.
20.
20. Overpayment
00
,
,
,
.
21. Amount of Line 20 to be Applied to 2021 Insurance Regulatory Charge
21.
00
,
,
,
.
22. Insurance Regulatory Charge to be Refunded
22.
00
Line 20 minus Line 21
Part 3.
Amount Due
23. Total Payment Due for 2020
,
,
,
.
$
$
Add Line 9 and Line 19 (An overpayment in one part cannot be used to offset
23.
00
amount due in the other part.)
Part 4. Installment Payments Made
(Do not include any negative amounts or amounts from Line 1 on Lines 2-4)
(1) Gross Premiums Tax
(2) Insurance Regulatory Charge
1.
Prior Year Credit Applied to 2020
(Gross Premiums Tax - from prior IB-43, Part 1, Line 11)
(Insurance Regulatory Charge - from prior IB-43, Part 2, Line 21)
2. Installment Payment made April 15, 2020
(Gross Premiums Tax - from IB-44, Part 1, Line 4)
(Insurance Regulatory Charge - from IB-44, Part 2, Line 10)
3.
Installment Payment made June 15, 2020
(Gross Premiums Tax - from IB-44, Part 1, Line 4)
(Insurance Regulatory Charge - from IB-44, Part 2, Line 10)
4.
Installment Payment made October 15, 2020
(Gross Premiums Tax - from IB-44, Part 1, Line 4)
(Insurance Regulatory Charge - from IB-44, Part 2, Line 10)
5.
Total Installment Payments Made in 2020
Add Lines 2 through 4
Legal Name
FEIN
Page 3, Form IB-43, Web, 1-21
Part 5. Adjusted Taxable Premiums Calculation
(See instructions for this form at https://www.ncdor.gov/insurance-gross-premiums-tax-returns-and-instructions)
Taxable
Percentage
Job Class Description
Job Class
Payroll Amount
Taxable Premiums
(00.00000%)
Total Taxable Premiums
Approved Experience Modification Factor
$
Total Adjusted Taxable Premiums
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