California Nonadmitted Insurance Tax Return

Nonadmitted Insurance Tax Return
2023 Form 570 Nonadmitted Insurance Tax Return
TAXABLE YEAR

2023

CALIFORNIA FORM

Nonadmitted Insurance Tax Return

570

Amended •
The policyholder completes this form.
Select calendar quarter during which the taxable insurance contract(s) took effect or was renewed.
Period ending:    □  March 31    □  June 30    □  September 30  □  December 31

Part I

Policyholder
□ SSN or ITIN □ FEIN □ CA Corp no. □ CA SOS file no.

Business name
First name

Initial

Last name

DBA (if applicable)
Address (apt./ste., room, PO box, or PMB no.)
City (If you have a foreign address, see instructions.)

State

ZIP code

Part II Tax Computation. See instructions.
 1 Gross premiums paid or to be paid on risks located entirely within California, and California is your principal place of
business or your principal residence. See instructions  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1
 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.
	

Total premiums returned $ 	

  6 Overpayments from prior quarters. Quarter/year

Quarter/year taxed 	
m m/ y

y

y

y

m m/ y

y

y

y

 . . . .  5

Policy No. 	

 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  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
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
payable to the “Franchise Tax Board”. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
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
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:
Business name

Contact person’s name

Business address

Contact person’s telephone

Sign
Here

Our privacy notice can be found in annual tax booklets or online. Go to ftb.ca.gov/privacy to learn about our privacy policy statement, or go to ftb.ca.gov/forms and search for
1131 to locate FTB 1131 EN-SP, Franchise Tax Board Privacy Notice on Collection. To request this notice by mail, call 800.338.0505 and enter form code 948 when instructed.
Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true,
correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Print or type elected officer's or authorized person’s name
Telephone
Elected officer's or authorized person’s signature

Date

▶

Print or type preparer’s name

Check if
self-employed

Paid
Preparer’s signature
Preparer’s
Use Only ▶

Date

□

Telephone
PTIN
Firm's FEIN

Business name (or yours, if
self-employed) and address
May the FTB discuss this return with the preparer shown above (see instructions)? . . . . . . . .  •

3681233

• Yes • No

Form 570 2022 Side 1

Policyholder Name: ________________________________________________________________ Policyholder ID No.:_____________________________

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
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.
(a)
Policy number

(b)
Name of each nonadmitted insurance company

(c)
Type of insurance coverage

(d)
Location of risks

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Side 2 Form 570 2022

3682233

PRINT CLEARLY
(e)
Total premium