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Form Iip-R - Annual Industrial Insurance (Workers Compensation) Reconciliation Premium Tax Return - 2008 Page 2

SCHEDULE 1

INDUSTRIAL INSURANCE PREMIUM TAX AND FEES ON RETALIATORY BASIS

(WORKERS COMPENSATION)

FOR YEAR ENDING DECEMBER 31, 2008

(A)

(B)

NEVADA BASIS

STATE OF INC

1. Gross Annual Premiums (Industrial Insurance Only)

2. Dividends Paid or Credited to Policy Holders

3. Gross Premiums written minus Dividends paid or Credited to Policy Holders

4. Taxes Payable (according to applicable rate) (Tax Rate for Nevada is 3.5%)

Must agree with Line 7, IIP-R on Annual Reconciliation Return

5. Retaliatory Assessment

INDUSTRIAL INSURANCE PREMIUM TAX ANNUAL RECONCILIATION RETURN

(WORKERS COMPENSATION) INSTRUCTIONS

A COPY OF THE NEVADA PAGE FROM ANNUAL STATEMENT MUST BE ATTACHED

This form is to be used if you were required to file quarterly Industrial Insurance Premium Tax returns during the year. The Nevada

premium tax rate is 3.5%. (Retaliatory statues, NRS 680A.330 requires you to use the higher tax rate charged by your domiciliary

state).

Schedule 1

Line 1 Gross Premiums/Considerations. Defined as all direct premiums written during the year for workers compensation.

Line 2 Dividends Paid or Credited to Policy Holders

Line 3 Gross Premiums written minus Dividends paid or credited to policy holders.

Line 4 Taxes Payable. Amount of premium tax due.

Line 5 Retaliatory Assessment

Annual Reconciliation Return

Line 1 through Line 4 Total Premiums/Considerations If figures for columns A and B differ, penalty and interest may apply.

Line 5 Total Premium/Considerations Add Lines 1 through 4.

Line 6 Net Direct Premiums Enter Line 5 Column B. Must agree with Schedule 1, Line 4A and state (Nevada) page.

IIP-R

Revised 2-2-09

Form Iip-R - Annual Industrial Insurance (Workers Compensation) Reconciliation Premium Tax Return - 2008 Page 2