Form 207f - Insurance Premiums Tax Return Form - Connecticut 2010
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1Department of Revenue Services
Form 207F
2010
State of Connecticut
Insurance Premiums Tax Return
PO Box 2990
Hartford CT 06104-2990
Nonresident and Foreign Companies
(Rev. 12/10)
Complete this return in blue or black ink only.
General Information
D. If this is a fi nal return, is the insurance company:
A.
Check if this is an amended return.
No longer licensed in Connecticut; out of business
B. Change of:
Address
Merged/reorganized _______________________
Domicile, enter new domicile: ___________________
Enter survivor’s CT Tax Registration No.
E. The insurance company is currently in:
C. If this is a short period,
Receivership
enter period covered by this return: __________________________
Rehabilitation
Name of company
Connecticut Tax Registration Number
Taxpayer
Date received (DRS use only)
Address
Number and street
PO Box
Type
Federal Employer ID Number (FEIN)
or
Print
City or town
State
ZIP code
Organized under the laws of
1
1
Enter gross direct premiums received during the calendar year. See instructions.
00
2
Dividends paid: See instructions.
2
00
Net direct premiums received during the year from ocean marine insurance policies written on property
3
3
00
located in this state
4
4
Benefi t payments from group health insurance premiums to the extent allowed by Conn. Gen. Stat. §12-210a
00
5
5
Total deductions: Add Lines 2, 3, and 4.
00
6
6
Taxable premiums: Subtract Line 5 from Line 1.
00
7
7
Multiply Line 6 by 1.75% (.0175).
00
8
8
Taxes and other obligations on retaliatory basis: See instructions.
00
9
9
Other obligations paid to Connecticut: See instructions.
00
10
10
Retaliatory computation: Subtract Line 9 from Line 8.
00
11
Tax: Enter Line 7 or Line 10 amount, whichever is greater.
11
00
12
Multiply Line 11 by 70% (.70). See instructions.
12
00
13
13
General business tax credits: See instructions.
00
14
14
Enter Line 12 or Line 13, whichever is less.
00
15
15
Enter CIGA assessment credit. See instructions.
00
16
16
Enter CLHIGA assessment credit. See instructions.
00
17
17
Total credits: Add Lines 14, 15, and 16.
00
18
18
Net tax: Subtract Line 17 from Line 11. If less than zero, enter “0.”
00
19
19
Overpayment applied from prior year
00
20
20
Payments made with estimated tax payment coupons Forms 207F ESA, ESB, ESC, and ESD
00
21
21
Payments made with extension request Form 207F EXT
00
22
22
Total prior payments: Add Lines 19, 20, and 21.
00
23
23
If Line 22 is greater than Line 18, enter amount overpaid.
00
Amount to be: credited to 2011 estimated tax (24a) $ __________________refunded (24b) $ ________________ 24
24
00
00
25
If Line 18 is greater than Line 22, enter amount owed.
25
If late: penalty (26a) $ __________________ plus interest (26b) $ ___________________ See instructions.
00
26
26
27
Interest on underpayment of estimated tax: Attach Form 207I. See instructions.
27
00
00
28
Balance due with this return. Make check payable to Commissioner of Revenue Services.
28
Visit the Department of Revenue Services (DRS) website at to pay electronically.
Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) and, to the best of my knowledge and
belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or document to DRS is a fi ne of not more than $5,000, imprisonment
for not more than fi ve years, or both. The declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge.
Signature of principal offi cer
Title
Date
Sign Here
Print name of principal offi cer
Telephone number
Keep a copy
(
)
of this return
Paid preparer’s signature
Date
Preparer’s SSN or PTIN
for your
records.
Firm name and address
FEIN
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