AB  25-122                                                                                                                      PRINT FORM RESET FORM
CD  (Rev.12-15/6)                                                                     b.
                                                                                      b                         *2512200W121506*
Texas Annual Insurance Tax Report - Supplement                                                                 d. Filing period              e.
(Independently Procured Insurance)
                                                                                                                                           b
a. T Code         b 71240
c. Taxpayer number                            Taxpayer name
b

This supplement cannot be processed without the report (Form 25-103).                                                                      I Type or print.
1. Policy number                                  2. Name of insurer

b                                                 b
3. Gross premium charged (Whole dollars only)           4. Premium allocated to Texas (Whole dollars only)     5. Effective date of policy
b $                                           .00       b  $                                               .00 b
6. Type of insurance

b
1. Policy number                                  2. Name of insurer

b                                                 b
3. Gross premium charged (Whole dollars only)           4. Premium allocated to Texas (Whole dollars only)     5. Effective date of policy
b $                                           .00       b  $                                               .00 b
6. Type of insurance

b
1. Policy number                                  2. Name of insurer

b                                                 b
3. Gross premium charged (Whole dollars only)           4. Premium allocated to Texas (Whole dollars only)     5. Effective date of policy
b $                                           .00       b  $                                               .00 b
6. Type of insurance

b
1. Policy number                                  2. Name of insurer

b                                                 b
3. Gross premium charged (Whole dollars only)           4. Premium allocated to Texas (Whole dollars only)     5. Effective date of policy
b $                                           .00       b  $                                               .00 b
6. Type of insurance

b
1. Policy number                                  2. Name of insurer

b                                                 b
3. Gross premium charged (Whole dollars only)           4. Premium allocated to Texas (Whole dollars only)     5. Effective date of policy
b $                                           .00       b  $                                               .00 b
6. Type of insurance

b
1. Policy number                                  2. Name of insurer

b                                                 b
3. Gross premium charged (Whole dollars only)           4. Premium allocated to Texas (Whole dollars only)     5. Effective date of policy
b $                                           .00       b  $                                               .00 b
6. Type of insurance

b

You have certain rights                                                       Total premiums allocated to Texas                                            under Chapters 552 and 559, Government Code,
to review, request and correct information we have on file about you. Contact for this page only.                               $              .00
us at the address or phone number listed on the report.                       (Forward to Form 25-103, Item 1)

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

                               Instructions for Completing the 
                               Texas Annual Insurance Tax Report - Supplement
                                   (Independently Procured Insurance)

GENERAL INSTRUCTIONS:

I To report more than six policies, please use additional supplement forms.
I TYPE or PRINT.
I Do not write in shaded areas.
I Forward the taxable Texas premium totals for all supplement forms to Form 25-103, Item 1.

SPECIFIC INSTRUCTIONS:

Item 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. 
  I 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.