Form 63-23p Draft - Premium Excise Return For Insurance Companies - 2012

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2012
Form 63-23P
Massachusetts
Premium Excise Return
Department of
for Insurance Companies
Revenue
For calendar year 2012 or taxable year beginning
2012 and ending
Name of company
Federal Identification number
State of incorporation
Mailing address
City/Town
State
Zip
Name of treasurer
Domestic insurers, check applicable gross investment income tax rate
.01
.008
.006
.004
.002
.000
3
Has the federal government changed your taxable income for any prior year which has not yet been reported to Massachusetts?
Yes
No
Domestic Casualty Insurers.
Enclose a copy of Schedule T of NAIC Annual Statement.
11 Taxable premiums (from Part 1, line 5, col. c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 $_______________ × .0228 = 3 1
12 Gross investment income (from Part 2, line 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 $ ______________ × applicable rate = 3 2
13 Fair Plan and Crime Prevention disbursement received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3
14 Credit recapture (enclose Schedule H-2) and/or additional tax on installment sales (see instructions) . . . . . . . . . . . . . . . . . . . 3 4
15 Excise due before credits. Add lines 1 through 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 5
Foreign Casualty Insurers.
Enclose a copy of Schedule T of NAIC Annual Statement.
16 Total net direct premiums for insurance of property or interests in Massachusetts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 6
17 Other premiums (Fair Plan and Crime Prevention) If included in Schedule T, enclose statement . . . . . . . . . . . . . . . . . . . . . . 3 7
18 Total premiums. Add lines 6 and 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
19 Dividend deduction. Premiums returned or credited to policyholders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 9
10 Taxable premiums. Subtract line 9 from line 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11 Tax calculation. Multiply line 10 by .0228 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 11
12 Tax computed under retaliatory provisions (enter full amount from Part 3, line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 12
13 Credit recapture (enclose Schedule H-2) and/or additional tax on installment sales (see instructions). . . . . . . . . . . . . . . . . . 3 13
14 Excise due before credits. Enter the larger of line 11 plus line 13 or line 12 plus line 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 14
Preferred Provider Arrangements
15 Gross premiums received for coverage of covered persons residing in Massachusetts (premiums for Medicare
supplemental Coverage are excludable) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 15
16 Premiums returned or credited to policyholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 16
17 Taxable amount. Subtract line 16 from line 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
18 Tax calculation. Multiply line 17 by .0228 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 18
19 Credit recapture (enclose Schedule H-2) and/or additional tax on installment sales (see instructions). . . . . . . . . . . . . . . . . . 3 19
20 Excise due before credits. Add lines 18 and 19. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 20
Under the penalties of perjury, I declare that to the best of my knowledge and belief, this return and enclosures are true, correct and complete.
Signature of appropriate corporate officer (see instructions)
Social Security number
Telephone number
Date
Signature of paid preparer
Employer Identification number
Address
Date
If you are signing as an authorized delegate of the appropriate corporate officer, check here
and enclose Massachusetts Form M-2848, Power of Attorney.
The Privacy Act Notice is available upon request. Mail to: Massachusetts Department of Revenue, PO Box 7052, Boston, MA 02204.
Form code 386 / Tax type 0119

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