Form Ipt-A - Annual Insurance Premium Tax Return 2010 Page 2
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5Nevada Department of Taxation Schedule 1
Statement of Premium Tax and Fees on Retaliatory Basis
For Year Ending December 31, 2010
Do NOT include Industrial Insurance
1. Gross Annual Life Insurance Premiums
2. Gross Annual Accident & Health Insurance Premiums
3. Gross Annual Property & Casualty Insurance Premiums
4. Deferred Tax Annuity Premiums
5. Current Tax Annuity Premiums
6. Other Considerations
7. Premiums and Considerations not reported in Schedule T
8. Total Annual Premiums/Considerations
9. Federally Qualified Plan Premiums
10. Social Security Act Title XVIII Premiums
11. Total Excluded Premiums
12. Current Deferred Tax Annuity Premiums
13. Total Income Derived from Direct Premiums Written
14. Dividends Paid in Cash
15. Dividends Applied to Paid-Up Additions or Renewal Premiums
16. Total Premium Deductions
17. Total Premiums/Considerations Subject to Tax
DO NOT REMIT THESE FEES TO THE DEPARTMENT OF TAXATION
Retaliatory worksheet
(A) Nevada Basis
(B) State of Domicile
18. Premium Taxes Due
19. _________________________________________ $___________________ @_______%
20. _________________________________________ $___________________ @_______%
21. _________________________________________ $___________________ @_______%
22. _________________________________________ $___________________ @_______%
23. _________________________________________ $___________________ @_______%
24. Total Taxes Due
25. Filing Annual Statement (Nevada $25)
26. Annual Licensing Fee (Nevada $2,450)
27. Annual Naic Fee (Nevada $26)
28. Filing Charter Documents (Nevada $10 each)
29. Filing Power of Attorney (Nevada $5)
30. Filing any other certificate form (Nevada $10 each)
31. Filing Certificate of Compliance (Nevada -0-)
32. Agent Licenses And Renewals (Nevada $15 - $125)
33. Filing Rates and Forms
_______________ @ $25 each
34. Filing Riders and Endorsements
_______________ @ $10 each
35. ______________________________________________________________ $_________
36. ______________________________________________________________ $_________
37. ______________________________________________________________ $_________
38. Total all Fees/Charges
39. Total Taxes and Fees
40. Retaliatory Assessment
IPT-A
Revised 1-3-11
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