Form IN-0581 "Statement of Premiums and Fees for Taxation - Life and Accident and Health Companies" - Tennessee

What Is Form IN-0581?

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

Form Details:

  • Released on December 1, 2012;
  • The latest edition provided by the Tennessee 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 printable version of Form IN-0581 by clicking the link below or browse more documents and templates provided by the Tennessee Department of Commerce and Insurance.

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Download Form IN-0581 "Statement of Premiums and Fees for Taxation - Life and Accident and Health Companies" - Tennessee

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FOR DEPARTMENT USE ONLY
CI373 121/970 ____________________
CI377 121/971 ____________________
STATE OF TENNESSEE
THE DEPARTMENT OF COMMERCE AND INSURANCE
P.O. BOX 198983
CI378
122/551 _______________________
Nashville, TN 37219-8983
(615) 741-1670
STATEMENT OF PREMIUMS AND FEES FOR TAXATION
CI364 880/554 _______________________
(To Be Filed On Or Before March 1)
LIFE AND ACCIDENT AND HEALTH COMPANIES
Scanned
Company Name
Contact Person
Amended
Address (No. & Street)
E-Mail Address
Calendar Year
NAIC CO.CODE
City, State & Zip
Phone Number/ Fax Number
Date Admitted to TN
Domiciliary State
Premiums
Tax
1. Life Premium Tax – (1.75% on taxable direct life premiums)
$
$
2. Accident and Health Premium Tax – (1.75% on taxable direct A & H premiums)
$
$
Do Not list a negative Tax amounts on any of the above lines; if negative, enter zero (0)
*3. Premiums, if any, required to balance with Schedule T
$
4. Total premiums reported on Schedule T (Tennessee Business)
$
$150.00 MINIMUM TAX
5. Total Tax (Sum of Lines 1 and 2)
( If less than $150.00, Enter
)
$
6a. Amount Paid TN Insurance Dept. Previous Three Quarters: Life Premium Tax
$
6b. Amount Paid TN Insurance Dept. Previous Three Quarters: Accident and Health Premium Tax
$
7a. TNInvestco Tax Credit (See instructions- Co. must include original Certificate for this cal. tax yr.)
$
7b. Credit Due Company for the TN Life and Health Insurance Guaranty Association Assessment
$
8. Total Deductions (sum of lines 6 thru 7b.) Note: Do not take credit for prior year overpayments
$
9. Total Tax Due (Line 5 Minus Line 8)
$
10. Annual Statement Filing Fee (Must be Remitted Even if Credit or Refund is Due)
$
515.00
11. Retaliatory Tax (As Computed in Schedule A)
$
12. TOTAL AMOUNT DUE (Sum of lines 9, 10, and 11)
$
Please attach a copy of Tennessee business page from the Annual Statement.
Make remittance payable to: TENNESSEE DEPT. OF COMMERCE & INSURANCE
* Explanation of Non-Taxable Premiums Required to Balance With Schedule T of Annual Statement. This exemption includes all annuity premiums
and premiums or considerations received under life insurance policies issued in connection with any pension plan, annuity plan, or profit sharing plan
qualified for Federal Income Tax advantage under part 1, subchapter D, subtitle A, IRS Code of 1954, including any amendments thereto and
successors thereof, and to any trust qualified under Section 501 (a). IRS Code of 1954, including amendments and successors thereto.
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Form IN-0581 Life Company Annual Form Rev 12/2012
Page 1 of 4
FOR DEPARTMENT USE ONLY
CI373 121/970 ____________________
CI377 121/971 ____________________
STATE OF TENNESSEE
THE DEPARTMENT OF COMMERCE AND INSURANCE
P.O. BOX 198983
CI378
122/551 _______________________
Nashville, TN 37219-8983
(615) 741-1670
STATEMENT OF PREMIUMS AND FEES FOR TAXATION
CI364 880/554 _______________________
(To Be Filed On Or Before March 1)
LIFE AND ACCIDENT AND HEALTH COMPANIES
Scanned
Company Name
Contact Person
Amended
Address (No. & Street)
E-Mail Address
Calendar Year
NAIC CO.CODE
City, State & Zip
Phone Number/ Fax Number
Date Admitted to TN
Domiciliary State
Premiums
Tax
1. Life Premium Tax – (1.75% on taxable direct life premiums)
$
$
2. Accident and Health Premium Tax – (1.75% on taxable direct A & H premiums)
$
$
Do Not list a negative Tax amounts on any of the above lines; if negative, enter zero (0)
*3. Premiums, if any, required to balance with Schedule T
$
4. Total premiums reported on Schedule T (Tennessee Business)
$
$150.00 MINIMUM TAX
5. Total Tax (Sum of Lines 1 and 2)
( If less than $150.00, Enter
)
$
6a. Amount Paid TN Insurance Dept. Previous Three Quarters: Life Premium Tax
$
6b. Amount Paid TN Insurance Dept. Previous Three Quarters: Accident and Health Premium Tax
$
7a. TNInvestco Tax Credit (See instructions- Co. must include original Certificate for this cal. tax yr.)
$
7b. Credit Due Company for the TN Life and Health Insurance Guaranty Association Assessment
$
8. Total Deductions (sum of lines 6 thru 7b.) Note: Do not take credit for prior year overpayments
$
9. Total Tax Due (Line 5 Minus Line 8)
$
10. Annual Statement Filing Fee (Must be Remitted Even if Credit or Refund is Due)
$
515.00
11. Retaliatory Tax (As Computed in Schedule A)
$
12. TOTAL AMOUNT DUE (Sum of lines 9, 10, and 11)
$
Please attach a copy of Tennessee business page from the Annual Statement.
Make remittance payable to: TENNESSEE DEPT. OF COMMERCE & INSURANCE
* Explanation of Non-Taxable Premiums Required to Balance With Schedule T of Annual Statement. This exemption includes all annuity premiums
and premiums or considerations received under life insurance policies issued in connection with any pension plan, annuity plan, or profit sharing plan
qualified for Federal Income Tax advantage under part 1, subchapter D, subtitle A, IRS Code of 1954, including any amendments thereto and
successors thereof, and to any trust qualified under Section 501 (a). IRS Code of 1954, including amendments and successors thereto.
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Form IN-0581 Life Company Annual Form Rev 12/2012
Page 1 of 4
STATE OF
RETALIATORY TAX
TENNESSEE COLUMN
INCORPORATION
COLUMN
Taxes and Fees
Taxes and Fees which
Schedule A
Payable to
a TN Company, with
(COMPUTATION OF RETALIATORY TAX)
Tennessee
identical Premium or
Please provide documentation of all assessments reported
other Income, would
have paid in your State
$515.00
1.
Filing Annual Statement
2.
Certificate of Authority Renewal (Company)
.
Department Licenses and Fees (Itemize) (attach details)
3
(a) _______________________________________
(b) _______________________________________
4.
Agents License Fees (Certificates of Authority)
Show how figure was calculated on Schedule B page 3
5.
Agents Examination Fees and Filing Fees (Itemize)
(a) _______________________________________
(b) _______________________________________
Premiums
6a. Tennessee Life Premium Tax
@ 1.75%
6b. Tennessee A&H Premium Tax
@ 1.75%
*6c. State of Incorporation Life Premium Tax
@ _____ %
*6d. State of Incorporation Annuities Premium Tax @ _____ %
*6e. State of Incorporation A&H Premium Tax
@ _____ %
7.
Additional Premium Tax of ______% Account of Aggregate City, County, or
Other Political Subdivisions (Example: Municipal Tax)
8.
Any Additional Tax, Fee or Obligation Subject to Retaliatory Law (Itemize)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
9.
TOTALS (TN Minimum-$515.00 Annual Statement Filing Fee plus $150.00 Premium Tax)
$
$
10. DEDUCT TAXES AND FEES PAYABLE TO TENNESSEE (From line 9)
( $
)
11. IF POSITIVE (PLUS) REMAINDER, ENTER ON PAGE 1, Line 11, RETALIATORY TAX (Line 9 Minus Line 10)
$
*
Explain any reduction of premiums from state of incorporation basis in line 6c, 6d and 6e.
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Form IN-0581 Life Company Annual Form Rev 12/2012
Page 2 of 4
Schedule B
Agent Licensing Fees
*
Residential and non-residential renewal fees for an agent’s license are $60.00 for every two (2) years or
$30.00 per year. These fees are the responsibility of the individual agent(s) to pay. An insurance company
may optionally pay the producer/agent renewal fees to Tennessee for the producer/agent; however, if the
insurance company chooses to optionally pay the fee for its Tennessee producer/agents, then it must choose
to report the domicile state's fee for renewal producer/agents in the domiciliary state box as listed below. This
applies even if the domiciliary state does not require the insurance company to pay producer/agent
renewal fees in the domiciliary state.
Appointment and termination fees are the responsibility of insurance companies to pay in Tennessee. List
appointment fees and terminations fees in state of domicile box only if it is required of Tennessee insurance
companies to pay to your domiciliary state."
Tennessee
# of Agents
$ per Agent
Total Agent Fees
Residential Appointments
$
15.00
Non-Residential Appointments
$
15.00
*Residential Renewals
*Non-Residential Renewals
Terminations
$
15.00
Total Agent Fees
Report total agent fees on Page 2 Schedule A line 4 Tennessee Column
Name of Domiciliary State: __________________________________
# of Agents
$ per Agent
Total Agent Fees
Residential Appointments
Non-Residential Appointments
Residential Renewals
Non-Residential Renewals
Terminations
Total Agent Fees
Report total agent fees on Page 2 Schedule A line 4 State of Incorporation Column
Page 3 of 4
Form IN-0581 Life Company Annual Form Rev 12/2012
STATEMENT OF PREMIUMS AND FEES FOR TAXATION MUST OBTAIN ORIGINAL SIGNATURE AND NOTARY
STATE OF
________________________________
COUNTY OF
____________________________
I,
_______________________________________________ , do hereby make oath that I am
_____________________________________
(Officer’s Name)
(Official Title)
of the
______________________________________________________________________________________________________________
(Company Name)
and that the foregoing Statement of Premiums and Fees for Taxation is true to the best of my knowledge, information and belief.
_____________________________
Signature of Officer
___________________________________
Notary Public
(SEAL)
Subscribed and Sworn before me
______________________
Date
My commission expires
______________________
Date
Page 1
TENNESSEE STATUTES APPLICABLE TO PREMIUM TAXES
Tenn. Code Ann. § 56-4-204
LINE 1
Tax on Life Premiums_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Tenn. Code Ann. § 56-4-205
Tenn. Code Ann. § 56-4-204
LINE 2
Tax on Accident and Health Premiums _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Tenn. Code Ann. § 56-4-205
LINE 5
Minimum Tax Stipulated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Tenn. Code Ann. § 56-4-205
LINE 7a TNInvestco Act Credit --------------------------------------------------------------------------------------------------
Tenn. Code Ann § 4-28-103
-
LINE 7b Tennessee Life and Health Insurance Guaranty Association Credit _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Tenn. Code Ann. § 56-12-212
LINE 10 Fees Collected by Commissioner _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Tenn. Code Ann. § 56-4-101
LINE 11 Reciprocity of Treatment (Retaliatory Tax) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Tenn. Code Ann. § 56-4-218
FAILURE TO FILE TAX RETURN Within Time Prescribed _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Tenn. Code Ann. § 56-4-216
FAILURE TO FILE ANNUAL STATEMENT Within Time Prescribed _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Tenn. Code Ann. § 56-1-502
Page 4 of 4
Form IN-0581 Life Company Annual Form Rev 12/2012
Page of 4