Form MO375-0411 "Life Insurance Companies" - Missouri

What Is Form MO375-0411?

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

Form Details:

  • Released on November 1, 2020;
  • The latest edition provided by the Missouri Department of Commerce and Insurance;
  • 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 fillable version of Form MO375-0411 by clicking the link below or browse more documents and templates provided by the Missouri Department of Commerce and Insurance.

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MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
MISSOURI INSURANCE TAXES FOR CALENDAR YEAR 2020
DUE MARCH 1, 2021
LIFE INSURANCE COMPANIES
MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
P.O. BOX 690
JEFFERSON CITY, MISSOURI 65102-0690
NAME OF COMPANY
MAILING ADDRESS
PREMIUM TAX CONTACT PERSON
TELEPHONE NUMBER
E-MAIL ADDRESS
STATE OF INCORPORATION
NAIC NUMBER (GROUP-COMPANY)
IS YOUR COMPANY PART OF A HOLDING COMPANY SYSTEM?
INSTRUCTIONS
Tax returns are due March 1. No authority exists for granting extensions of time for filing the annual premium tax return, or for making
payment of any of the quarterly tax assessments. Only one copy of the return needs to be filed with the Missouri Department of
Commerce and Insurance at P.O. Box 690, Jefferson City, MO 65102-0690. Overnight deliveries should be sent to 301 West High Street,
Room 530, Jefferson City, MO 65101. Be sure you have included your 9-digit NAIC number on the premium tax return. To ensure that
your tax return and supporting documentation remains together through mailing and processing, please securely staple or binder clip the
documentation. DO NOT file a copy of this return with the Missouri Department of Revenue.
DO NOT send payment with this tax return. The March 1 quarterly payment for 2021 should be sent to the Missouri Department of
Revenue, P.O. Box 898, Jefferson City, MO 65105-0898 along with a copy of your completed March assessment form. A blank copy
of the March assessment form will be sent electronically to your company in January. The June 1, September 1, and December 1
assessments will be sent to you electronically at least a month before the due date. The 2020 annual tax reconciling payment will be
included on your June 2021 assessment. DO NOT make a payment of the remainder of your 2020 annual tax until you receive the
June 2021 assessment. Only use the quarterly assessment forms that are provided by the State of Missouri.
Claims for refund of tax overpayment must be filed with the Missouri Department of Revenue pursuant to 136.035 RSMo.
See page 9 of this return for a checklist of necessary items to be included with this return. For frequently asked questions or forms, go
to our website at www.insurance.mo.gov; see Companies/Forms/Tax. If you have any questions concerning this premium tax return,
please call 573-526-4986 or 573-751-1929.
THE FOLLOWING SECTION IS REQUIRED TO BE COMPLETED AND NOTARIZED
NAME OF PRESIDENT
NAME OF SECRETARY
being duly sworn, on oath say that they are the PRESIDENT and the SECRETARY, respectively of the ___________________________
__________________________________________________________________________________________________ and that the
attached is a true, full and correct statement of Missouri direct premiums received during the year of 2020 and include all policies and premiums
wherever written covering property and interest in the State of Missouri without deductions except as therein set forth and the amount of all
taxes, license fees, assessments and all other obligations due and/or paid to the respective states, and of Missouri credits for the stated year.
SIGNATURE OF PRESIDENT
SIGNATURE OF SECRETARY
4
4
COUNTY (OR CITY OF ST. LOUIS)
STATE OF
NOTARY PUBLIC EMBOSSER OR
BLACK INK RUBBER STAMP SEAL
SUBSCRIBED AND SWORN BEFORE ME, THIS
USE RUBBER STAMP IN CLEAR AREA BELOW.
DAY OF
YEAR
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
PAGE 1
MO 375-0411 (11-2020)
EX
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Print
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MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
MISSOURI INSURANCE TAXES FOR CALENDAR YEAR 2020
DUE MARCH 1, 2021
LIFE INSURANCE COMPANIES
MISSOURI DEPARTMENT OF COMMERCE AND INSURANCE
P.O. BOX 690
JEFFERSON CITY, MISSOURI 65102-0690
NAME OF COMPANY
MAILING ADDRESS
PREMIUM TAX CONTACT PERSON
TELEPHONE NUMBER
E-MAIL ADDRESS
STATE OF INCORPORATION
NAIC NUMBER (GROUP-COMPANY)
IS YOUR COMPANY PART OF A HOLDING COMPANY SYSTEM?
INSTRUCTIONS
Tax returns are due March 1. No authority exists for granting extensions of time for filing the annual premium tax return, or for making
payment of any of the quarterly tax assessments. Only one copy of the return needs to be filed with the Missouri Department of
Commerce and Insurance at P.O. Box 690, Jefferson City, MO 65102-0690. Overnight deliveries should be sent to 301 West High Street,
Room 530, Jefferson City, MO 65101. Be sure you have included your 9-digit NAIC number on the premium tax return. To ensure that
your tax return and supporting documentation remains together through mailing and processing, please securely staple or binder clip the
documentation. DO NOT file a copy of this return with the Missouri Department of Revenue.
DO NOT send payment with this tax return. The March 1 quarterly payment for 2021 should be sent to the Missouri Department of
Revenue, P.O. Box 898, Jefferson City, MO 65105-0898 along with a copy of your completed March assessment form. A blank copy
of the March assessment form will be sent electronically to your company in January. The June 1, September 1, and December 1
assessments will be sent to you electronically at least a month before the due date. The 2020 annual tax reconciling payment will be
included on your June 2021 assessment. DO NOT make a payment of the remainder of your 2020 annual tax until you receive the
June 2021 assessment. Only use the quarterly assessment forms that are provided by the State of Missouri.
Claims for refund of tax overpayment must be filed with the Missouri Department of Revenue pursuant to 136.035 RSMo.
See page 9 of this return for a checklist of necessary items to be included with this return. For frequently asked questions or forms, go
to our website at www.insurance.mo.gov; see Companies/Forms/Tax. If you have any questions concerning this premium tax return,
please call 573-526-4986 or 573-751-1929.
THE FOLLOWING SECTION IS REQUIRED TO BE COMPLETED AND NOTARIZED
NAME OF PRESIDENT
NAME OF SECRETARY
being duly sworn, on oath say that they are the PRESIDENT and the SECRETARY, respectively of the ___________________________
__________________________________________________________________________________________________ and that the
attached is a true, full and correct statement of Missouri direct premiums received during the year of 2020 and include all policies and premiums
wherever written covering property and interest in the State of Missouri without deductions except as therein set forth and the amount of all
taxes, license fees, assessments and all other obligations due and/or paid to the respective states, and of Missouri credits for the stated year.
SIGNATURE OF PRESIDENT
SIGNATURE OF SECRETARY
4
4
COUNTY (OR CITY OF ST. LOUIS)
STATE OF
NOTARY PUBLIC EMBOSSER OR
BLACK INK RUBBER STAMP SEAL
SUBSCRIBED AND SWORN BEFORE ME, THIS
USE RUBBER STAMP IN CLEAR AREA BELOW.
DAY OF
YEAR
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
PAGE 1
MO 375-0411 (11-2020)
EX
COMPANY NAME
NAIC NO.
Report the amount of Missouri direct premiums received, either in cash or notes, or both, and report the amount of dividends
allowed policyholders for the year ending December 31, 2020. Commission retained by agents shall also be included with your
direct premium written.
After January 1, 1987, Missouri no longer taxes annuities. Use Line 1b to report the annuity considerations received by your
company, and line 2g to deduct this amount out of taxable premium. Companies that have a Flexible Premium Deferred Annuity
account on which prior tax had been deferred must continue to file the FPDA report and make payment of tax due on that account
with respect to annuity considerations received before January 1, 1987.
$ ________________
1. a. Amount of Direct Life Premiums Received, Cash or Notes, or Both . . . . . . . . . . . . . . . . . . . . . . .
$ ________________
b. Amount of Direct Annuity Consideration (148.390 RSMo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________________
c. Amount of Accident and Health Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________________
d. SUBTOTAL of Direct Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________________
e. Flexible Payment Deferred Annuities Account (20 CSR 200-3.010) . . . . . . . . . . . . . . . . . . . . . . . .
Total Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________________
2. Deductions from Direct Premiums: Life, Annuity, Accident and Health
a. Dividends on Accident and Health Business (148.390 RSMo) . .
$ ________________
b. Dividends Paid in Cash or Left on Deposit (148.390 RSMo) . . .
$ ________________
c. Dividends Applied to Pay Renewal Premiums . . . . . . . . . . . . . . .
$ ________________
d. Dividends Applied to Provide Paid-up Additions or Shorten the
Endowment or Premium Paying Period (Must be included
in Item No. 1) (148.390 RSMo) . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________________
e. Retirement, Profit Sharing or Pension Plans (non-annuity)
(Include backup documentation with return) (148.390 RSMo) .
$ ________________
f. Health Insurance Benefits (Losses) for Employer Groups and Union
Groups (Complete Group Accident and Health Loss Report
on Page 7) (148.390.2 RSMo) . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________________
g. Exempt Annuity Consideration (Same amount as line 1b)
(148.390 RSMo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________________
h. _____________________________ . . . . . . . . . . . . . . . . . . . . . .
$ ________________
i. _____________________________ . . . . . . . . . . . . . . . . . . . . . .
$ ________________
j. Title XVIII Medicare premiums (42 C.F.R. 422.404, etc.) . . . . . .
$ ________________
Total Deductions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________________
3. Net Premiums Subject to Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________________
4. 2% Tax on Net Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________________
MO 375-0411 (11-2020)
PAGE 2
COMPANY NAME
NAIC NO.
5. Net Tax To Be Carried Forward To Page 4, Line 13 (Same as Page 2, Line 4)
$____________
6. Credits Allowed
Total Credit Available
Amount Deducted
For Current Year
On This Return
Income Tax (148.400 RSMo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________
Franchise Tax (148.400 RSMo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________
2020 Examination Fees (148.400 RSMo) . . . . . . . . . . . . . . . .
$____________
$____________
Valuation Fees (148.400 RSMo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________
Registration Fees - Paid in 2020 (148.400 RSMo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________
MO Health Insurance Pool (376.975 RSMo) . . . . . . . . . . . . . .
$____________
$____________
Examination Fee Carryover 2015-2019 (148.400 RSMo) . . . . .
$____________
$____________
Personal Property Tax - Paid in 2020 (148.400 RSMo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________
Missouri Life & Health Guaranty Assn. (376.745 RSMo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________
Affordable Housing (32.111 RSMo) . . . . . . . . . . . . . . . . . . . . . . . . $____________
$____________
Neighborhood Development (32.110 RSMo) . . . . . . . . . . . . . . . . . $____________
$____________
Neighborhood Assistance (32.115 RSMo) . . . . . . . . . . . . . . . . . . . $____________
$____________
Infrastructure Development (100.286 RSMo) . . . . . . . . . . . . . . . . $____________
$____________
Enterprise Zone/Urban Redevelopment (135.225 RSMo) . . . . . . . $____________
$____________
Low Income Housing (135.352 RSMo) . . . . . . . . . . . . . . . . . . . . . $____________
$____________
Small Business Investment (135.403 RSMo) . . . . . . . . . . . . . . . . $____________
$____________
Youth Opportunities (135.460 RSMo) . . . . . . . . . . . . . . . . . . . . . . $____________
$____________
CAPCO Investment (135.503 RSMo) . . . . . . . . . . . . . . . . . . . . . . $____________
$____________
Neighborhood Preservation (135.535 RSMo) . . . . . . . . . . . . . . . . $____________
$____________
Domestic Violence Shelters (135.550 RSMo) . . . . . . . . . . . . . . . . $____________
$____________
Maternity Home Facilities (135.600 RSMo) . . . . . . . . . . . . . . . . . . $____________
$____________
Historic Structure Rehabilitation (253.550 RSMo) . . . . . . . . . . . . . $____________
$____________
Agricultural Utilization (348.430 RSMo) . . . . . . . . . . . . . . . . . . . . . $____________
$____________
New Generation Cooperative Incentive (348.432 RSMo) . . . . . . . . . . . $____________
$____________
New Enterprise Creation (620.650 RSMo) . . . . . . . . . . . . . . . . . . $____________
$____________
OTHER ___________________________ . . . . . . . . . . . . . . . . . . $____________
$____________
OTHER ___________________________ . . . . . . . . . . . . . . . . . . $____________
$____________
OTHER ___________________________ . . . . . . . . . . . . . . . . . . $____________
$____________
7. Total Credits Allowed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$____________
8. Net Missouri Tax (Line 5 less Line 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$____________
(Round to nearest dollar)
MO 375-0411 (11-2020)
PAGE 3
COMPANY NAME
STATE OF DOMICILE
RETALIATORY COMPARISON (375.916 RSMo)
The retaliatory portion of the Missouri tax return compares the aggregate burden which would be placed upon your company by
the State of Missouri to the aggregate burden which would be placed by your state of incorporation upon a hypothetical Missouri
company writing the same amount of premium that your company is writing in Missouri.
The Agent information on line 4 should agree with your company’s Insurance Producers Report form, which was due on or before
February 10, 2021. Please show the fees charged by your state of incorporation for appointments, terminations and renewals.
Additional lines are provided if different rates are charged for resident and non-resident agents.
Please include in the State of Incorporation column ALL taxes, fees, and assessments which a Missouri company operating in your
state of incorporation would have been subject to during the 2020 calendar year. Include with the return a copy of the assessments,
invoices, or tax documents along with the calculations based off of your Missouri premium amount.
The Annual Renewal Fee for 2020 was due July 1, 2020. The Annual Renewal Fee amount for Foreign Life Companies has
been preprinted on line 1 in the Missouri column.
State of
State of
Missouri
Incorporation
Basis
Basis
2,000
1. Filing Annual Statement/Annual Filing Fee . . . . . . . . . . . . . . . . . . . . . . .
$ _____________
$ _______________
2. Filing Renewal Application for Certificate of Authority . . . . . . . . . . . . . . .
$ _______________
3. Filing Any Other Paper Required to be Filed
$ _______________
4. Agents:
$_______________
Missouri Appointments
______@ state of incorp. rate $_______ (Res Non-Res Both)
$_______________
Missouri Terminations
______@ state of incorp. rate $_______ (Res Non-Res Both)
$_______________
Total Missouri Renewals ______@ state of incorp. rate $_______ (Res Non-Res Both)
$_______________
___________________ ______@ state of incorp. rate $_______ (Res Non-Res Both)
$_______________
___________________ ______@ state of incorp. rate $_______ (Res Non-Res Both)
$_______________
___________________ ______@ state of incorp. rate $_______ (Res Non-Res Both)
PREMIUM TAX CREDITS SHOULD NOT BE INCLUDED IN THE RETALIATORY TAX CALCULATIONS.
5. Municipal License Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _____________
$ _______________
6. Other ________________________________________ . . . . . . . . . . . .
$ _____________
$ _______________
7. Other ________________________________________ . . . . . . . . . . . .
$ _____________
$ _______________
8. Other ________________________________________ . . . . . . . . . . . .
$ _____________
$ _______________
9. Other ________________________________________ . . . . . . . . . . . .
$ _____________
$ _______________
10. Other ________________________________________ . . . . . . . . . . . .
$ _____________
$ _______________
11. Other ________________________________________ . . . . . . . . . . . .
$ _____________
$ _______________
12. Other Taxes (Specify) ___________________________ . . . . . . . . . . . .
XXXXXXXXXXXX
$ _______________
_____________________________________________ . . . . . . . . . . . .
XXXXXXXXXXXX
$ _______________
_____________________________________________ . . . . . . . . . . . .
XXXXXXXXXXXX
$ _______________
13. Premium Tax, (MO column from Page 3, Line 5) . . . . . . . . . . . . . . . . . .
$ _____________
$ _______________
14. TOTAL TAXES, LICENSES AND FEES . . . . . . . . . . . . . . . . . . . . . . . . .
(a) $ _____________ (b) $ _______________
15. Retaliatory Tax Amount Before Credits [Subtract Line 14(a) from Line 14(b)]
$ _______________
16. Credit Allowed - New Market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _______________
17. Retaliatory Tax Amount (Round to nearest whole dollar) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _______________
MO 375-0411 (11-2020)
PAGE 4
COMPANY NAME
NAIC NO.
CREDITS FOR GUARANTY ASSOCIATION ASSESSMENTS (376.745.1 RSMo)
Credits for Missouri Life and Health Insurance Guaranty Association assessments begin the year after the year of assessment.
Only class B assessments made by the Missouri Life and Health Guaranty Association are deductible from premium tax at
20% for five years.
You must include copies of your certificates of contribution for guaranty association credit. Please list credits under
appropriate year and type; do not combine assessments.
Please complete the following information to support the credit amount shown on line 6 for Missouri Life & Health Guaranty
Association Credit.
ASSESSMENT YEAR
ASSESSMENT AMOUNT
PERCENT
CREDIT
2015 ANNUITY
20%
2015 HEALTH
20%
2015 LIFE
20%
2016 ANNUITY
20%
20%
2016 HEALTH
2016 LIFE
20%
2017 ANNUITY
20%
2017 HEALTH
20%
2017 LIFE
20%
2018 ANNUITY
20%
2018 HEALTH
20%
2018 LIFE
20%
2019 ANNUITY
20%
2019 HEALTH
20%
2019 LIFE
20%
TOTAL
MO 375-0411 (11-2020)
PAGE 5