Form 207 - Insurance Premiums Tax Return Domestic Companies - 2003

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Department of Revenue Services
Form 207
2003
State of Connecticut
PO Box 2990
Insurance Premiums Tax Return
Hartford CT 06104-2990
Domestic Companies
(Rev. 12/03)
Purpose: Each domestic insurance company authorized to conduct insurance business in Connecticut must file this return on or before
March 1, 2004, to report its insurance premiums tax liability for calendar year 2003.
Attach the following to this return:
A copy of Schedule T;
Connecticut business page from the Annual Statement filed with the Insurance Department;
2003 Schedule GAA, if applicable;
2003 Form 207I, if applicable.
CT Insurance Premiums Tax Registration No.
Please
K
make
Date Received (For Department Use Only)
changes to
your name
K
and
address if
Federal Employer Identification Number
shown
K
incorrectly
Check if this is a new address
Check if this is an amended return
1 Gross direct premiums (less return premiums, including cancellations) received during the calendar year from
policies written on property or risks located or resident in this state, excluding annuity considerations and premiums
received for reinsurance assumed from other companies
1
00
2 Dividends paid to policyholders on direct business, not including dividends paid on account of the ownership of stock
2
00
3 Taxable premiums (Subtract Line 2 from Line 1)
3
00
K
4 Tax: Multiply Line 3 by 1.75% (.0175)
4
00
5 Assessment credits: (5a) CIGA $ ___________________________ (5b) CLHIGA $ _________________________
K
5
00
6 Insurance Department assessment credit (See instructions on back)
K
6
00
7 General business tax credits (See instructions on back)
K
7
00
8a Add Line 6 and Line 7
8a
00
8b Multiply Line 4 by 70% (.70) (See instructions on back)
8b
00
8c Enter Line 8a or Line 8b, whichever is less
8c
00
9 Add Line 5 and Line 8c
9
00
10 Subtract Line 9 from Line 4 (If less than zero, enter zero (0))
10
00
11 Overpayment applied from prior year
11
00
12 Payments made with estimated tax payment coupons (Forms 207 ESA, ESB, ESC, and ESD)
12
00
13 Payments made with extension request (Form 207/207F EXT) (See instructions on back)
13
00
14 Total prior payments (Add Lines 11, 12, and 13)
14
00
K
15 If Line 14 is greater than Line 10, enter amount overpaid
15
00
K
(16a) $_________________ Refunded
16 Amount to be: Credited to 2004 estimated tax
K
(16b) $__________________ 16
00
K
17 If Line 10 is greater than Line 14, enter amount owed
17
00
(18a) $ ___________________ plus interest
(18b) $ ___________________ (See instructions)
18 If late: penalty
K
K
18
00
19 Interest on underpayment of estimated tax (Attach Form 207I) ( See instructions on back)
K
19
00
K
20 Balance due with this return (Make check payable to: Commissioner of Revenue Services)
20
00
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 to DRS is a fine of not more than $5,000,
or imprisonment for not more than five 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 Officer
Title
Date
Sign Here
Print Name of Principal Officer
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
Federal Employer Identification Number

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