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Form 207f Esa - Estimated Insurance Premiums Tax Payment Coupon Foreign And Nonresident Insurance Companies Page 2

207F ESD

- Fourth Installment

Organized Under Laws of

________________

Department of Revenue Services

Estimated Insurance Premiums Tax Payment Coupon

For Calendar Year Ending

Foreign and Nonresident Insurance Companies

State of Connecticut

PO Box 2990 Hartford CT 06104-2990

(Rev. 12/01)

CT Insurance Premiums Tax Reg. No.

Tax shown on 2001 Form 207F, Line 15

Multiply the tax that will be shown on 2002 Form 207F by 90% (.90)

Date Received (DRS USE ONLY)

Required annual payment (Enter the lesser of Line 1 or Line 2)

Federal Employer ID Number

Amount paid with Forms 207F ESA, 207F ESB, and 207F ESC plus overpayment

from prior year applied to estimated tax for current year

Payment due with this coupon (Subtract Line 4 from Line 3)

Please change

Due Date:

December 15

name or

mailing

Make Checks Payable To:

address, or

Commissioner of Revenue Services

both,

Mail To:

Department of Revenue Services

if shown

Processing Section

incorrectly

PO Box 2990

at right

Hartford CT 06104-2990

Form 207f Esa - Estimated Insurance Premiums Tax Payment Coupon Foreign And Nonresident Insurance Companies Page 2