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DEPARTMENT OF INSURANCE, STATE OF WYOMING
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106 EAST 6th AVENUE, CHEYENNE, WYOMING 82002
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Company Name:
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Address:
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NAIC No.
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FEIN
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State of Domicile:
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2025 AMENDED PREMIUM TAX RETURN
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Please note that any amended filings need to be made in hard copy and mailed to the Department.
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Column 1 reports the amount of tax a Wyoming company would pay to your domiciled state if they had your written premium, and column 2 reports the amount of tax your company would pay to Wyoming based on Wyoming statutes.
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SUMMARY OF PREMIUM TAXESColumn 1
State of Incorporation		Column 2
State of Wyoming
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TAXES:
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1. Life and Disability (Sch. I – Line 13)$0.00$0.00
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2. Annuities (Sch. III – Line 12b)$0.00$0.00
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3. Health (Sch. IV – Line 8c)$0.00$0.00
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4. Property & Casualty (Sch. V – Line 13d)$0.00$0.00
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5. Wet Marine & Transportation (Sch. VI – Line 9e) $0.00$0.00
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6. Title (Sch. VII – Line 9f)$0.00$0.00
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7. Fire Marshal and/or Fire Department
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8. Other
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9. TOTAL TAXES$0.00$0.00
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FEES:
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10. Filing of Annual Statement/Annual Renewal*$500.00
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11. Other
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12.TOTAL FEES: $0.00$500.00
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13. TOTAL TAXES & FEES - RETALIATORY BASIS$0.00$500.00
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14. Enter the larger of col. 1 or col. 2, Total Taxes & Fees – Retaliatory Basis$500.00
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15. Tax on High Value Life Insurance Policies (Sch. II – Line 4a)$0.00
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16. TOTAL TAXES & FEES (Add lines 14 and 15)$500.00
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LESS PAYMENTS AND CREDITS:
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17. Quarterly Premium Taxes Paid
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18. Prior year overpayment
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19. Allowable Tax Credits (Schedule VIII, line 28g)$0.00
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20. Other (Must attach schedule explaining credit taken)$0.00
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21. If Amended, Original Amount Paid$0.00
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NET AMOUNT$500.00
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* WYOMING ANNUAL STATEMENT FILING FEES:
Domestic & Foreign Insurers -- Wyo. Stat. § 26-4-101(a)(i)(B)………………………$500.00
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By selecting agree in the field below, the authorized officer of the company certifies, under penalties provided by the laws of Wyoming, that this premium tax return (including accompanying schedules and statements) has been examined and is to the best of the authorized officer’s knowledge, information, and belief, a true, correct and complete premium tax return, made in good faith for the taxable period indicated.
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Attestation (select one)(Authorized Officer)
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(Date)(Officer Email)
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(Telephone Number)(Officer Title)
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SCHEDULE I
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LIFE, ACCIDENT & HEALTH BLANK (LIFE & DISABILITY TAX)Column 1
State of Incorporation		Column 2
State of Wyoming
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1. Total Life and Disability Premium Income
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2. Other Income
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3. TOTAL INCOME$0.00$0.00
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DEDUCT:
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4. Return Premiums on Canceled Policies
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5. Current Dividends Paid
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6. Life Premiums (Qualified Plans – Internal Revenue Code)
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7. Current Dividends Paid (Qualified Plans – Internal Revenue Code)
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8. Life Premiums Exceeding $100,000 per Life Policy for Policies Issued on or After January 1, 2021. (Enter on Schedule II, line 2a, column 2)
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9. Other Deductions
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10. TOTAL DEDUCTIONS$0.00$0.00
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11. Net Taxable Premiums, if negative enter 0$0.00$0.00
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12. Tax Rate0.75%
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13. Premium Tax - Life and Disability$0.00$0.00
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SCHEDULE II
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HIGH VALUE LIFE INSURANCE POLICIES TAXThis tax is not subject to retaliationColumn 2
State of Wyoming
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1a. Number of Policies Issued on or After January 1, 2021.
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2a. Life Premiums Exceeding $100,000 per Life Policy for Policies Issued on or After January 1, 2021. (From Schedule I, Line 8)
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3a. Tax Rate0.075%
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4a. Premium Tax on High Value Life Policies$0.00
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SCHEDULE III
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LIFE, ACCIDENT & HEALTH BLANK (ANNUITY TAX)Column 1
State of Incorporation		Column 2
State of Wyoming
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1b. Total Annuity Considerations Premium Income
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2b. Other Income
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3b. TOTAL INCOME$0.00$0.00
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DEDUCT:
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4b. Return Premiums on Canceled Policies
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5b. Current Dividends Paid
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6b. Annuity Premiums (Qualified Plans – Internal Revenue Code)
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7b. Current Dividends Paid (Qualified Plans – Internal Revenue Code)
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8b. Other Deductions
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9b. TOTAL DEDUCTIONS$0.00$0.00
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10b. Net Taxable Premiums, if negative enter 0 $0.00$0.00
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11b. Tax Rate1.00%
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12b. Premium Tax - Annuities$0.00$0.00
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SCHEDULE IV
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HEALTH BLANK (HEALTH TAX)Column 1
State of Incorporation		Column 2
State of Wyoming
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1c. Total Premiums Written
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2c. Other Income
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3c. TOTAL INCOME$0.00$0.00
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DEDUCT:
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4c. Allowable Deductions (attach supporting documentation)
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5c. TOTAL DEDUCTIONS$0.00$0.00
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6c. Next Taxable Premiums, if negative enter 0$0.00$0.00
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7c. Tax Rate0.75%