Form T-71h - Health Insurance Companies Tax Return Of Gross Premiums - 2010

Form T-71H

State of Rhode Island and Providence Plantations

HEALTH INSURANCE COMPANIES TAX RETURN OF GROSS PREMIUMS

HEALTH

for Calendar Year Ending December 31, 2009

INSURANCE

Due on or before March 1, 2010

2010

NAME

ADDRESS

CITY

STATE

ZIP CODE

FEDERAL IDENTIFICATION NUMBER

.

STATE OR COUNTRY OF INCORPORATION OR ORGANIZATION

COMPANY TYPE:

.

THIS FORM IS TO BE USED BY NONPROFIT HOSPITAL SERVICE CORPORATIONS, NONPROFIT DENTAL CORPORATION,

NONPROFIT MEDICAL SERVICE CORPORATIONS AND HEALTH MAINTENANCE ORGANIZATIONS

NOTE ATTACH LEGIBLE COPY OF SCHEDULE T AND SCHEDULE OF DIRECT BUSINESS IN THIS STATE FROM THE

ANNUAL STATEMENT SUBMITTED TO THE INSURANCE COMMISSIONER

Tax Computation

Tax and Fee

Direct Premiums (Gross less return premiums from Schedule T, Part 1 of Annual Statement to Insurance

.

.

1

1

Commissioner) .................................................................................................................................................................

Amount

.

TAX - 2.0% (0.02) of Line 1..............................................................................................................................................

2.

2

Credits and

.

.

RI Credits: Form #__________ $________ Form #__________ $__________ Form #__________ $____________

3

3

Payments

4.

TAX AFTER CREDITS - LINE 2 LESS LINE 3 ...............................................................................................................

4.

5.

Payments made on 2009 Declaration of Estimated Tax ....................................................

5.

6.

Other Payments .................................................................................................................

4.

6.

7.

TOTAL PAYMENTS - Add lines 5 and 6 ..........................................................................................................................

7.

Balance Due

8.

Net Tax Due - Line 4 minus Line 7 .................................................................................................................................

8.

9.

Interest Due - 18% per annum (1.5% per month) ...........................................................................................................

9.

10.

Total due with return - Add lines 8 and 9 ........................................................................................................................

10.

Refund

11.

Overpayment - Line 7 minus Line 4 ................................................................................................................................

11.

12.

Amount of overpayment to be applied to Estimated Tax for 2010 Calendar Year ..........................................................

12.

13.

Amount to be refunded - Line 11 minus Line 12 ............................................................................................................

13.

CERTIFICATION: This certification must be executed or the return must be sworn before some person authorized to administer oaths.

Under penalties of perjury, I hereby certify that I have personal knowledge of the statements and other information constituting this return, that the same are true, correct

and complete to the best of my knowledge and belief.

Date

Signature of authorized officer

Title

Date

Signature of preparer

Address of preparer

MAY THE DIVISION CONTACT YOUR PREPARER ABOUT THIS RETURN? YES

NO

Phone number

MAILING ADDRESS: OVERPAYMENTS/REFUNDS - RI DIVISION OF TAXATION, ONE CAPITOL HILL, PROVIDENCE, RI 02908-5806

PAYMENTS - RI DIVISION OF TAXATION, ONE CAPITOL HILL, PROVIDENCE, RI 20908-5807

key 13