Form 25-104 Texas Annual Insurance Tax Report - Surplus Lines / Purchasing Groups - Texas

Form 25-104 is a Texas Comptroller of Public Accounts form also known as the "Texas Annual Insurance Tax Report - Surplus Lines / Purchasing Groups". The latest edition of the form was released in October 27, 2018 and is available for digital filing.

Download a PDF version of the Form 25-104 down below or find it on Texas Comptroller of Public Accounts Forms website.

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AB CD
*2510400W101827*
PRINT FORM
RESET FORM
25-104
b
b.
(Rev.10-18/27)
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.10-18/27)
(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 www.comptroller.texas.gov.
AB CD
*2510400W101827*
PRINT FORM
RESET FORM
25-104
b
b.
(Rev.10-18/27)
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.10-18/27)
(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 www.comptroller.texas.gov.
Form 25-104 (Back)(Rev.10-18/27)
Instructions for Completing the Texas Annual Insurance Tax Report
Surplus Lines Agents/ Purchasing Groups
NOTE: Reference to "agents" includes agents and agencies in these instructions. Refer also to Publication 94-431
"Guidelines for Premium Tax Compliance with the Nonadmitted and Reinsurance Reform Act" for additional information.
Who Must File
All surplus lines agents licensed in Texas and all purchasing groups registered in Texas must file this report, even if no tax is due. Surplus lines agents are required to
report premium on policies placed with domestic surplus lines insurers licensed in Texas.
NOTE: Surplus lines agents reporting surplus lines and purchasing group business must complete Sections III and IV.
Purchasing groups should report in Section IV only.
When to File
The report and payment are due on March 1 of the year following the tax year.
Section I
Total Business Reported to the Surplus Lines Stamping Office of Texas (SLSOT)
Specific Instructions:
Item A - Texas premiums - Enter the total Texas premiums, net of returned premiums, for policies reported to the SLSOT during the tax year, where Texas is the home
state of the insured.
Item B - Texas premiums - Enter the total Texas premiums, net of returned premiums, for policies NOT YET reported to the SLSOT during the tax year, where Texas is the
home state of the insured.
Item C - Non-taxable premiums - Enter the non-taxable premiums, net of returned premiums, and whether or not reported to the SLSOT, for policies where Texas is the
home state of the insured and where the premiums are exempt or preempted from taxation.
Item D - Other states' premiums - For multi-state policies where Texas is the home state of the insured, enter the total premiums, net of returned premiums, included in
Item A that cover risks located outside of Texas. Texas is entitled to tax on 100% of the policy premium when Texas is the home state of the insured; however
the reporting of premium to the SLSOT by state for risks covered under a multi-state policy is requested for data collection purposes.
Note: Premium reported to the SLSOT in the “Breakdown of States Summary” also includes premium reported to other states.
Item E - Non-taxable premiums - This category does not apply to policies that are effective on or after July 21, 2011.
Item F - Other states' premiums - This category does not apply to policies that are effective on or after July 21, 2011.
Section II
Tax Base Election for Surplus Lines Agents
Surplus lines agents who received a license during the reporting year must elect one of the tax base options shown.
Rule 34 TAC, Sec. 3.822, provides specific information on the requirements for reporting surplus lines tax. Agents have the option of reporting tax using a premium-written
or premium-received basis and may change their election every four years. An agent who changes from a premium-received to a premium-written basis will owe taxes on
all outstanding receivables as of January 1 of the year of the change. If an agent fails to file the election, the agent will be subject to tax on a premium-written basis.
Section III
Surplus Lines Agents
These premiums will not necessarily match the premiums shown in Section I, because they are based on the reporting method chosen. The term "premium" includes all
premiums, premium deposits, membership fees, registration fees, assessments, dues and any other consideration for surplus lines insurance. Texas premiums include:
premiums written or received for new or renewal Texas or multi-state policies when Texas is the home state of the insured.
I
Exempt premiums are premiums for a surplus lines 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. Effective Jan. 1, 2014, premiums on risks or exposures under ocean marine insurance coverage of
stored or in-transit baled cotton for export are exempt from surplus lines premium tax.
Federal preemptions to state taxation for surplus lines insurance include premiums for policies that are issued to the following entities:
the Federal Deposit Insurance Corporation (FDIC), when it acts as the
I
receiver of a failed financial institution that holds the property being insured;
the National Credit Union Administration;
I
a federally chartered credit union; and
I
Indian Tribal Nations (see Publication 94-142).
I
Endorsements and audits on surplus lines insurance policies, whether
generating additional premium or resulting in a return of premium, must be
reported for the tax year in which the endorsement or audit occurs, not for the tax
year in which the original policy was reported. The tax for endorsements and
audits that generate return premiums due a policyholder must be calculated using
the tax rate that was originally charged.
Texas returned premiums - Report the unearned portion of the premium that is credited or refunded to a policyholder as a result of cancellation or premium adjustment prior
to the policy expiration. An agent reporting on the premium received basis will not have returned premiums.
Section IV
Purchasing Groups
Purchasing groups obtaining coverage from insurers licensed in Texas or surplus lines agents licensed in Texas do NOT owe tax on this report, but must file a zero report.
Specific Instructions
Item 12 - Penalty and interest
If tax is paid 1-30 days late: Enter penalty of 5% (.05) of Item 11.
Electronic reporting and payment options
I
If tax is paid 31-60 days late: Enter penalty of 10% (.10) of Item 11.
are available 24 hours a day, 7 days a week.
I
If tax is paid over 60 days late: Enter penalty of 10% (.10) of Item 11 plus interest.
Have this form available when you log on.
I Calculate interest at the rate published online at
www.comptroller.texas.gov/taxes/file-pay/
www.comptroller.texas.gov/taxes/file-pay/interest.php, or call 1-877-447-2834 for
the applicable interest rate.
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