Form Dexm - Domestic Companies Annual Report - 2006 Page 2
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5DEXM (10-06)
Page 2
SCHEDULE A
DOMESTIC LIFE INSURANCE COMPANIES
MUST BE COMPLETED BY ALL TAXPAYERS
PREMIUM TAX
STATE OF
NEW JERSEY BASIS
1 . Life Insurance Premium
2 . Individual Accident and Health
3 . Group Accident and Health
4 . All Other explain
5 . Total premiums per Schedule T (reconcile if different) lines 1 to 4
6 . Catchall attach computation
7 . Total Premiums (lines 5 and 6)
8 .
Dividends paid in cash: excluding $ ____________dividends on Qualified Pension Plans
9
Dividends used for renewal: excluding $ _________dividends on Qualified Pension Plans
10 .
Dividends left on deposit: excluding $ ___________dividends on Qualified Pension Plans
11
Life premiums on qualifies pension plans (Attach documentation)
12 . All Other explain
13 .
Total deductions (lines 8 to 12) attach a copy of New Jersey State page 24
of Annual Statement as filed with the New Jersey Department of Banking and Insurance
14 . Taxable Premiums (line 7 less line 13)
TAX COMPUTATION
Type
TAXABLE PREMIUMS
Rate
Tax
(See Note Below)
15 . Life
$
2.1%
16 . Individual A & H
$
2.1%
17 . Group A & H
$
1.05%
xxxxxx
18 . Total (Lines 15 thru 17)
$
xxxxxxxxxxx
CALCULATION OF TOTAL AMOUNT DUE
19 . Other Credits * -- Attach Detailed Schedule
20 . Smart Moves For Business Program Tax Credit from Form 307 (see instructions)
21 . Guaranty Fund Assessment Credit (from Schedule D, Line 8 on Page 4)
22 . Total Tax Credits (Total of Line 19 to line 21)
23 . Balance of Tax Liability Due (Line 18 less line 22)
24 .
Credit for Prepayment of Premium Tax paid March 1 and June 1 of prior calendar year
25 . Balance Due (Line 23 less line 24)
26 . Prepayment of 2007 Tax -- 50% of line 18
27 . Total Amount Due State of New Jersey (Line 25 plus line 26)
28 . If line 25 plus line 26 is less than zero enter the amount of the overpayment
29 . Amount of line 28 to be applied to June 1, 2007 prepayment
30 . Amount of line 28 to be refunded
PAYMENT OF THE AMOUNT INDICATED AT LINE 27 MUST BE SUBMITTED TO THE DIVISION OF
TAXATION AT THE ADDRESS INDICATED ON THE FIRST PAGE OF THIS RETURN.
NOTE: If taxable premiums are determined as provided in N.J.S.A. 54:18A-6 (12 1/2% limitation), then Schedule B,
Calculation of Taxable Premiums as provided in N.J.S.A. 54:18-A-6 must be completed.
* Requires proof of payment
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