25-122                                                                                                                                          PRINT FORM RESET FORM
         (Rev.12-15/6)                                                               b.

                                                                                                                                        d. Filing period             e.
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a. T Code         71240
c. Taxpayer number                             Taxpayer name

(Independently Procured Insurance)                                                   b Texas Annual Insurance Tax Report - Supplement

1. Policy number                               2. Name of insurer
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3. Gross premium charged                               4. Premium allocated to Texas                                                    5. Effective date of policy  Type or print.
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6. Type of insurance     (Whole dollars only) (Whole dollars only)
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1. Policy number                               2. Name of insurer
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3. Gross premium charged                               4. Premium allocated to Texas                                                    5. Effective date of policy
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6. Type of insurance     (Whole dollars only) (Whole dollars only)

1. Policy number                               2. Name of insurer
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3. Gross premium charged                               4. Premium allocated to Texas                                                    5. Effective date of policy
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6. Type of insurance     (Whole dollars only) (Whole dollars only)

1. Policy number                               2. Name of insurer
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3. Gross premium charged                               4. Premium allocated to Texas                                                    5. Effective date of policy
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6. Type of insurance     (Whole dollars only) (Whole dollars only)

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3. Gross premium charged                               4. Premium allocated to Texas                                                    5. Effective date of policy
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6. Type of insurance     (Whole dollars only) (Whole dollars only)

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6. Type of insurance     (Whole dollars only) (Whole dollars only)

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                                                                             (Forward to Form 25-103, Item 1)

Form 25-122 (Back)(Rev.12-15/6)

GENERAL INSTRUCTIONS:

    To report more than six policies, please use additional supplement forms.Instructions for Completing the 
    TYPE or PRINT.             Texas Annual Insurance Tax Report - Supplement (Independently Procured Insurance)
    Do not write in shaded areas.
    Forward the taxable Texas premium totals for all supplement forms to Form 25-103, Item 1.

SPECIFIC INSTRUCTIONS:

IIIIItem 1 - Policy number.    Enter the unique identification number assigned to a policy, contract, binder or other
    evidence of coverage.
Item 2 - Name of Insurer. Enter the exact name of the insurance company that is providing coverage as it
    appears on the policy, contract, binder or other evidence of coverage.
Item 3 - Gross Premium Charged.    Enter the total amount of premium charged by the insurer for the coverage
    provided under the policy, regardless of the location of the risks being insured under the policy.
Item 4 - Premium allocated to Texas. 
     Enter the amount of premium from Item 3, where Texas is the home state of the insured.
Item 5 - Effective Date of Policy. Enter the date on which the insurance was procured, continued or renewed. 
    Endorsements and audits on independently procured insurance policies must be reported for the tax 
    year based on the date in which the endorsement or audit occurs.
Item 6 - Type of Insurance.    Enter the specific type of insurance provided under the policy. 

    I