Michigan Department of Treasury 4925 Rev 1114 Instructions for Payment of Health InHealth Insurance Claims Assessment Quarterly and Annual Payments Segment Identifier TXP TXP01 Federal Empl ID: 868817
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1 Period for which the Health Insurance Cl
Period for which the Health Insurance Claims Assessment was accrued in TXP04 Amount type "T" for tax TXP05 Amount of Health Insurance Claims Assessment being paidTXP06 Amount type "P" for penalty TXP07 Amount of penalty being paid in "$$$$$$$$cc" format ("cc" cents must be TXP08 Amount type "I" for interest TXP09 Amount of interest being paid in "$$$$$$$$cc" format ("cc" cents must be NOTE: Fields TXP06, TXP07, TXP08 and TXP09 are optional and only need to be NOTE: TXP10 is a mandatory field. No character(s
2 ) should follow the terminator
) should follow the terminator Michigan Department of Treasury 4925 (Rev. 11-14) Instructions for Payment of Health In Health Insurance Claims Assessment (Quarterly and Annual Payments) Segment Identifier "TXP" TXP01 Federal Employer Identification Number or Michigan Department of Treasury TXP02 Tax type code (5-digits) 07100” - Health Insurance Claims Assessment Quarterly Payment “07150” - Health Insurance Claims Assessment Annual Payment TXP03 Tax period end dat