570 Form Fillable Nonadmitted Insurance Tax Return
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

1 Gross premiums paid or to be paid on risks located entirely within California and California is your principal place of 2 Gross premiums paid or to be paid by California home state insured including policies with risks outside California 2 3 Total taxable premiums Add line 1 and line 2 3 4 Total tax Multiply line 3 by 3% ( 03) (There is no stamping fee ) 4 5 3% of returned premiums previously taxed Attach copies of all contracts See instructions 6 Overpayments from prior quarters Quarter/year 6 7 Prepayments See instructions 7 8 Total premiums returned overpayments or prepayments Add line 5 through line 7 8 9 Balance Subtract line 8 from line 4 If the amount on line 8 is more than the amount on line 4 see instructions 9 916 845 6500 from outside the 916 845 6500 fuera de los Estados Business name (or yours if Call the FTB for information about the COMPLIANCE MS F182 Elected officer or authorized person s signature FRANCHISE TAX BOARD Give the FTB any information that is missing Gross premiums on businesses governed by Home state insured or home state insured Home state The state where the insured Insurance coverage for which a tax on the m m / y y y y Multistate risk A risk covered by a NONADMITTED INSURANCE TAX MS F182 PO BOX 307 PO BOX 942867 Preparer s signature Principal place of business The state Principal residence The state where the Print or type elected officer or authorized person s name Print or type preparer s name RANCHO CORDOVA CA 95741 0307 Respond to certain FTB notices about math SACRAMENTO CA 94267 0651 self employed) and address SSN or ITIN FEIN CA Corp no CA SOS file no TAX FORMS REQUEST UNIT The entity is not authorizing the paid preparer Total premiums returned $ Quarter/year taxed Policy No 5 WITHHOLDING SERVICES AND (reinsurance of the liability of an admitted 10 Penalty for late payment of tax See instructions 10 11 Interest on late payment See instructions 11 12 Payment due Add line 9 through line 11 If the result is positive enter here Make a check or money order 13 Overpayment Add line 9 through line 11 If result is negative enter here 13 14 Overpayment to be applied to the next quarter See instructions 14 15 Refund Subtract line 14 from line 13 15 2014 return with the paid preparer who signed 3681143 3682143 888 792 4900 916 845 7448 or call the Withholding A policyholder may have to file up to four A Purpose a refund abbreviation of the state where the risk is located activities in more than one state the state in activities; or if the insured s high level officers Additional Information Address (apt /ste room PO Box or PMB no ) address and a valid taxpayer identification Agents or brokers with a valid power of attorney all information using CAPITAL LETTERS If allocated Amended amended return and write copy in red across amended return See General Information E Amended Returns for more information Amended returns must be filed within four years amount on line 8 subtract line 8 from line 4 and an amended Form 570 Enter the calendar and Postal Code Follow the country s practice for and Reinsurance Reform Act (NRRA) which and the policy number that the returned premiums and where the insured s high level officers anything (including any additional tax liability) applicant A person whose home state is April June September 1 as the premiums are for policies related to risks Asistencia Por Internet y Tel fono Attach a copy of the original return behind the Attach copies of all contracts for changes to Attach copies of all contracts where there was a Attorney Declaration If the entity wants to revoke authorizes the collection of tax on 100% of authorizing the FTB to call the paid preparer authorizing the paid preparer to: B Who Must Pay Nonadmitted be paid by California home state insured for all behalf of the insured the refund will be mailed to belief it is true correct and complete Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge business activities outside the U S the Business Address Business name business or your principal residence See instructions 1 by email go to ftb ca gov and search for C Tax Rate CA Corp no or CA SOS file no on the check or calendar quarter calendar quarter Note: Enter only premiums for calendar quarter the overpayment occurred For California California and who has received a certificate California conforms to the Nonadmitted CALIFORNIA FORM California home state insured then all premiums cancellation or reduction of premiums on which Check if check or money order payable to the Franchise Check the Amended box at the top of the form City (If you have a foreign address see instructions ) State ZIP Code Telephone Code Section 1775 5 (surplus lines tax) Column a Enter the policy number for each Column b Enter the name of all the Nonadmitted Column c Enter the type of insurance coverage Column d Enter the full name or the two letter column e Column e Enter the total premium amount for completing Form 570 by hand enter all the Contact Person s Name Contact Person s Phone contract during the calendar quarter from an Contract effective date Return due date contract Enter only policies related to risks within contract is allocated contract took effect or was renewed: contracts in each calendar quarter corporation number (CA Corp no ); or California correct an error on the original return correct an error on the original return or to claim country s name coverage both inside and outside of California covering risks Also use Form 570 to file an credited to your next quarter s return D When and Where to File date paid Interest compounds daily and the date see the instructions for line 10 days during a calendar year; or if the insured s DBA (if applicable) Definitions direct control and coordinate the business discapacidades auditivas y del habla Do not file an amended return to claim returned Do Not Round Cents to Dollars On this form do not round cents to the nearest whole dollar Do not show net or negative amounts on line 1 due date a penalty of 10% of the amount of tax due will be imposed Enter 10% of the amount of during the calendar quarter because of E Amended Returns each contract each quarter and/or policy Electronic Funds Transfer (EFT) To submit your employer identification number (FEIN); California Enter the amounts with dollars and cents enter the balance on line 9 You have tax due If Enter the business or individual policyholder Enter the total premiums returned quarter/year entering the postal code Do not abbreviate the errors offsets and return preparation example if the calendar quarter and tax year is expires later F Third Party Designee File an amended Form 570 to claim a refund or File Form 570 on or before the first day of the First name following order: City Country Province/Region for all nonadmitted insurance placed in a single For all other questions unrelated to withholding for each contract If your policy covers more than For more information go to ftb ca gov and for policies entered into or renewed during the For Privacy Notice get FTB 1131 ENG/SP for the calendar quarter during which the returned Foreign Address Enter the information in the Form 570 C1 2013 Side 1 Form 570 If the returned premiums are from Form 570 Instructions 2013 Page 1 Form 570 tax returns in one year if the forms and publications at ftb ca gov FRANCHISE TAX BOARD from the date this tax return was filed If the entity from the return FTB Nonadmitted Insurance Desk at: General Information get form FTB 3520 Franchise Tax Board Power of gross premium is due or has been paid by gross premium is due or has been paid by risk gross premium paid or to be paid less premiums headquarters or the insured s high level hearing or speech impairments if 100% of the insured risk is located in a If the entity wants to allow the FTB to discuss its If the Yes box is checked the entity is If you are an agent or broker filing this return on If you are an agent or broker with a valid power of attorney authorizing you to file this return on behalf of the insured enter the following information: If you do not know if the insurer is authorized If you have questions contact the in that calendar quarter during which the taxable include a stamping fee include interest with your late payment or include independently purchases or renews an insurance individual the individual s principal residence; individual whose signature appears in the Paid information below information requested using black or blue ink Initial Instructions for Form 570 Instructions for line 12 Insurance Code Insurance Companies for each contract insurance contract is allocated insurance contract(s) took effect or were renewed Insurance Tax insured resides for the greatest number of insured s taxable premium for that insurance insurer and marine aircraft and interstate insurer including wholly owned subsidiaries insurer or a person who is an applicant interest and bill you for it interest rate is adjusted twice a year If you do not Internet and Telephone Assistance is allocated; or if the insured maintains its is now the entire gross premium charged on all it check the Yes box in the signature area of January March June 1 July September December 1 June September or December) the applicable Last name Line 1 Enter all gross premiums paid or to be line 1 through line 15 of the amended return use Line 10 If you do not pay the tax due by the Line 11 Interest will be charged on any late Line 12 Enter the total amount due Make your Line 14 Enter the amount of overpayment to be line 15 of this form Line 2 Enter all gross premiums paid or to line 4 subtract line 4 from line 8 and enter the Line 5 Enter 3% of the premiums returned Line 6 Enter the amount of overpayment you Line 7 Enter any payments made before filing Line 9 If the amount on line 4 is more than the Location of Risks locations of the risk separately longer occurs Mail Form 570 and payment to: maintains its principal place of business or if May the FTB discuss this return with the preparer shown below? See instructions Yes No money order Check the EFT box if you made more than one quarter or policy attach a schedule more than one state name Doing Business As (DBA) if applicable Name of Each Nonadmitted Insurance Company Nonadmitted Insurance Desk at 916 845 7448 nonadmitted insurance for the California home nonadmitted insurance tax payment using EFT Nonadmitted Insurance Tax Return nonadmitted insurance tax was paid nonadmitted insurer are subject to tax as long nonadmitted insurer with insured exposures in nonpayment or late payment is due to fraud ) not apply to the business if any shown in that not authorized to transact insurance business in number (TIN) The following are acceptable number Example: 111 Main Street PMB 123 October December March 1 of Attorney is on file allowing the FTB to do so of business or principal residence then it is of premiums among the states for taxation no of the amount of tax due will be imposed when of the insured s taxable premium for that of the original due date or within one year from officers direct control and coordinate the on the bottom separately Do not create a schedule to report additional policies We only accept and process official versions of Side 2 of Form 570 on which nonadmitted insurance tax was paid one state then use additional lines to list the only a portion of it the FTB will compute the or evidence of coverage as set forth in or otherwise represent the entity before or to access the TTY/TDD numbers see the OR to get forms by mail write to: OR write to: Page 2 Form 570 Instructions 2013 paid on risks located entirely within California Part I Policyholder Part II Tax Computation Part II Tax Computation (Do not use negative numbers See instructions ) Part III Insurance Contracts Part III Insurance Contracts If you have more than 23 policies to report enter the additional policies on another Side 2 of Form 570 Total each Side 2 payable to the Franchise Tax Board See instructions Check the box if paying via EFT EFT n 12 payment and penalty from the due date to the Period ending: m March 31 m June 30 m September 30 m December 31 PO BOX 942867 policies issued by a nonadmitted insurer for policies related to risks within the U S policies Thus if a person is determined to be a policy as issued by an eligible surplus line Policy Number Policyholder Name: Policyholder ID No : policyholder purchases nonadmitted insurance premium on which a tax has been paid Do not premium whichever is later premiums See the Specific Instructions for line 5 premiums were received Refunds resulting from Preparer s Preparer s Use Only section of the return It does principal residence is located outside the U S PRINT CLEARLY Private Mail Box (PMB) Include the PMB in processing of the return or the status of any proper credit to your FTB account provided by the contract provisions of Insurance Code Section 1760 5 quarter and taxable year as MM YYYY of the quarter during which a nonadmitted insurance railroad insurance) reduction of premiums returned or cancellation References in these instructions are to the California related refund or payments related to all insurance policies obtained from a related to risks within the U S requested to be applied from a prior quarter result in brackets on line 9 Your credits exceed retention groups pursuant to Insurance Code Return to determine the tax on premiums paid or returned because of cancellation or reduction of Returned premiums must be claimed on a return returned premiums must be claimed within four Revenue and Taxation Code (R&TC) and the California SACRAMENTO CA 94267 0651 search for nonadmitted insurance tax Secretary of State (CA SOS) file number Print section Section 132 Section 1764 of the Insurance Code or a See line 5 for returned premiums Only use line 1 Select calendar quarter during which the taxable insurance contract(s) took effect or was renewed self employed September 30 2012 enter 09 2012 Services and Compliance telephone service at showing the amount of returned premiums from Side 2 Form 570 C1 2013 Sitio web: ftb ca gov Specific Instructions state insured Enter only premiums for policies state outside the insured s principal place state to tax a home state insured so proration state to which the greatest percentage of the subscription services surplus line brokers pursuant to Insurance Tax Board Write the calendar quarter (March tax not paid by the due date (A penalty of 25% taxable premium for that insurance contract taxable premium for that insurance contract is TAXABLE YEAR taxable year Form 570 and your SSN ITIN FEIN taxpayer identification number (ITIN); federal Tel fono: 800 852 5711 dentro de los Estados Telephone Telephone: 800 852 5711 from within the that was not applied on a previously filed return the address field Write PMB first then the box the amount on line 8 is more than the amount on the amounts that should have been reported on the authorization before it ends notify the FTB in The authorization will automatically end one year the date of the overpayment whichever period the face of the original return When completing the FTB the original return the premiums of California home state insured the processing of its return The entity is also the requested information in the space below the return If the return is being filed after the due the return This authorization applies only to the the state to which the greatest percentage The tax is imposed on a home state insured who The tax rate is 3% This rate is applied to the The tax will not be imposed on any of the following: The total gross premium paid or to be paid the U S These payments may include amounts from third month following the close of any calendar through line 4 to account for returned premiums through line 4 to report taxable premiums paid or TINs: social security number (SSN); individual to answer any questions that may arise during to be paid during the calendar quarter to be paid to nonadmitted insurers on contracts to California risk The NRRA only allows one to conduct business in California call the FTB to file a return on behalf of the insured must enter to receive any refund check bind the entity to To receive nonadmitted insurance tax information To submit payment electronically see the Specific Total Total Enter the total of Form 570 Side 2 Total Premium transaction with one underwriter or group of TTY/TDD: 800 822 6268 for persons with TTY/TDD: 800 822 6268 personas con Type of Insurance Coverage Under penalties of perjury I declare that I have examined this return including accompanying schedules and statements and to the best of my knowledge and underwriters whether in one or more policies Unidos United States Use Form 570 Nonadmitted Insurance Tax Use Only use the following tax type code EFT code 02020 wants to expand the paid preparer s authorization Website: ftb ca gov were originally taxed on the lines provided on when California only taxed premiums related where the greatest percent of the insured s where the insured maintains its headquarters which the greatest percentage of the insured s which were entered into or renewed during the within the United States This is a change from writing or call 800 852 5711 year from the date of cancellation or reduction of years from the date the return was filed or one years from the original due date of the return four You can download view and print California tax you in the name of the insured if a signed Power You must use the correct EFT code to ensure your payment by EFT your tax