Form 207 - Insurance Premiums Tax Return Domestic Companies

Department of Revenue Services

Form 207

2009

State of Connecticut

Insurance Premiums Tax Return

PO Box 2990

Hartford CT 06104-2990

Domestic Companies

(Rev. 12/09)

Complete this return in blue or black ink only.

General Information

Check if this is an amended return.

D. If this is a ﬁ nal return, is the insurance company:

B. Change of:

Address

No longer licensed in Connecticut; out of business

Domicile, enter new domicile: ___________________

Merged/reorganized

_______________________

Enter survivor’s CT Tax Registration No.

C. If this is a short period,

E. The insurance company is currently in:

enter period covered by this return: __________________________

Receivership

Rehabilitation

Name of company

Connecticut Tax Registration Number

Taxpayer

Address

Number and street

PO Box

Date received (DRS use only)

Please

type

or print.

(FEIN)

City or town

State

ZIP code

Federal Employer ID Number

1. Gross direct premiums received during the calendar year: See instructions.

2. Dividends paid: See instructions.

3. Taxable premiums: Subtract Line 2 from Line 1.

4. Tax: Multiply Line 3 by 1.75% (.0175).

5. Multiply Line 4 by 70% (.70). See instructions.

6 Insurance Department assessment credit: See instructions.

7. General business tax credits: See instructions.

8. Add Line 6 and Line 7.

9. Enter Line 5 or Line 8, whichever is less.

10. Enter your CIGA assessment credit. See instructions.

11. Enter your CLHIGA assessment credit. See instructions.

12. Add Lines 9, 10, and 11.

13. Net tax: Subtract Line 12 from Line 4. If less than zero, enter zero “0.”

14. Overpayment applied from prior year

15. Payments made with estimated tax payment coupons Forms 207 ESA, ESB, ESC, and ESD

16. Payments made with extension request Form 207/207 HCC EXT

17. Total prior payments: Add Lines 14, 15, and 16.

18. If Line 17 is greater than Line 13, enter amount overpaid.

(19a) $ _____________ refunded

19. Amount to be: credited to 2010 estimated tax

(19b) $ _______________ 19

20. If Line 13 is greater than Line 17, enter amount owed.

(21b) $ _________________ See instructions.

21. If late: penalty (21a) $ _________________ plus interest

22. Interest on underpayment of estimated tax: Attach Form 207I. See instructions.

23. Balance due. Make check payable to: Commissioner of Revenue Services.

Visit the Department of Revenue Services (DRS) website at to pay electronically.

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 or document to the Department

of Revenue Services (DRS) is a ﬁ ne of not more than $5,000, or imprisonment for not more than ﬁ ve 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 ofﬁ cer

Title

Date

Sign Here

Print name of principal ofﬁ cer

Telephone number

Keep a copy

(

)

of this return

Paid preparer’s signature