Form 323 - Quarterly Premium Tax Statement - 2009

ADVERTISEMENT

No staples please
Original
Amended
STATE OF HAWAII
DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS (“DCCA”)
DO NOT WRITE IN THIS AREA
INSURANCE DIVISION
ATTN: SUSAN HANSEN
ATTN: SUSAN HANSEN
OR
P. O. Box 3614
335 Merchant Street, Room 213
Honolulu, HI 96811-3614
Honolulu, HI 96813
2009 QUARTERLY PREMIUM TAX STATEMENT
Statement on business transacted during:
QUARTER ENDED MARCH 31, 2009
(Due April 30, 2009)
NAIC # _______________
Name of Insurer: _______________________________________________________________________________________
Address for TAX: _______________________________________________________________________________________
Report the actual taxable premiums during period of this Statement.
PREMIUMS
AMOUNT OF TAX
RATE
(Round to nearest dollar)
(Round to nearest dollar)
1.
All Insurance---other than life, annuities,
$ ___________________
& ocean marine . . . . . . . . . . . . . . . . . . . . . . . . .
4.2650% $ ____________________
$ ___________________
2.
Life Insurance, not including annuities . . . . . . . .
2.7500% $ ____________________
$ ___________________
3.
Ocean Marine Insurance
0.8775% $ ____________________
(Gross Underwriting Profit)
4.
TOTAL PREMIUM TAX LIABILITY (Add lines 1, 2 and 3) . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ____________________
$ ___________________
5.
Tax Credit, 1% of Line 1 and/or Line 2 . . . . . . . . .
1.0000% $ (___________________)
(If qualified – see HRS §431:7-207)
6.
SUBTOTAL (Line 4 less Line 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ____________________
7.
Less prior year (2008) premium tax overpayment, if any . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ (___________________)
BALANCE DUE (If Line 6 minus Line 7 is positive) OR ACTUAL OVERPAYMENT AMOUNT
(If Line 6 minus Line 7 is negative) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ____________________
CHECK PAYABLE TO: DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS (“DCCA”), STATE OF HAWAII
No Payment
Check
EFT
Method of Tax Payment:
ALL authorized insurers must file four (4) Quarterly Premium Tax Statements regardless of tax liability. Statements are due on
or before the last day of the calendar month following the quarter in which the tax accrued.
Date ________________________
Signature of Officer of Insurer
PRINT Name and Title of Officer
I01
Form 323 (Revised 10/08)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 4