CALENDAR YEAR 2014 PREMIUM TAX FINAL FOR VEHICLE COMPANIES
Office of Superintendent of Insurance, 1120 Paseo De Peralta Room 433, Santa Fe, NM 87501, P.O. Box 1689 Room 433, Santa Fe, NM 87504-1689
Make check payable to “Office of Superintendent of Insurance”
For calendar year ending December 31, 2014. Due April 15, 2015.
Late, unsigned and/or incomplete reports will be assessed a penalty pursuant to NMSA 1978, Section 59A-6-4.
Company Name: ___________________________________________________
Company Address: _________________________________________________
_________________________________________________
Contact: _____________________________________________
Phone/Email: _____________________________________________
CLASS
1. Premiums
written from
policies within the
State of New
Mexico as per NM
State Business page
NM Co. # __________
Class: ___________
NAIC: __________
AMENDED, Reason:_________________________
Name or address change (Submit address change form)
DEDUCTIONS ALLLOWED: Supporting Documents Required
2.Political
Subdivisions
(MUST ATTACH
BREAKDOWN)
3. Dividends
paid/credited to
policyholders
(Applies to
Reinsurance
ONLY)
4. Premiums received from
Authorized companies for
reinsurance on NM risks.
5. Net Premiums
on which the New
Mexico tax is
based.
(19.1) Pvt. Passengers Auto
No Fault – Personal
Injury Protection
(19.2) Other Pvt. Passenger
Auto Liability
(19.3) Commercial Auto No
Fault – Personal
Injury Protection
(19.4) Other Commercial
Auto Liability
(21.1) Pvt. Passenger AutoPhysical Damage
(21.2) Commercial AutoPhysical Damage
(22) Aircraft (All Perils)
Miscellaneous
1.TOTALS
2. Premium Tax Due (3.003% of Line 1, Column 5)
3. Less 1st and 2nd 2014 quarterly taxes paid (include credit taken)
4. Less 3rd and 4th 2014 quarterly taxes paid (include credit taken)
5. Less year 2013 remaining credit not used in line 3 & 4
6. Net Premium Tax Due
#78
Total Amount of Check
Check #
The signature for the Authorized Preparer means that: 1) The Authorized Preparer is authorized by the company’s Board of Directors to
prepare this report. 2) The Authorized Preparer has examined this report. 3) The contents of this report are true and correct to the best of the
Authorized Preparer’s knowledge.
NOTARY SEAL
____________________________
President/Authorized Signature
_____________________________
Secretary/Treasurer/Authorized Signature
Notary Signature _____________________
My Commission Expires _______________
Subscribed and sworn before me this _____ day of _______, 20___
Postmarked _______
Initials
_________
Form 303 Updated March 11, 2015