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

Part 1. Premium Excise.

Domestic casualty insurers only must complete this schedule.

01 Total of all net direct premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1

02 Net direct premiums for insurance of property or interests in other states or countries where a tax is actually paid by said

company or its agents (Supporting schedule is required showing by states the total business written. Copy of Schedule T

is accepted, if admitted states are designated.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2

b. States or

countries in which

Total

Massachusetts

company pays no tax

add col’s. a and b

03 Total net direct premiums subject to tax. Subtract line 2 from line 1 . . . . . . 3

04 Premiums returned or credited to policyholders. . . . . . . . . . . . . . . . . . . . . . 4

05 Taxable premiums. Subtract line 4 from line 3. Enter the amount in

5c on page 1, line 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

06 Are net direct premiums reported in lines 1 and 3?

Yes

07 Have all dividends claimed as a deduction in line 4 been included as taxable premiums on this return or on a previous Massachusetts return?

Yes

08 If the answer to lines 6 or 7 is “No,” please explain: __________________________________________________________________________________

Part 2. Gross Investment Income.

Domestic casualty insurers only must complete this schedule.

From Exhibit of Net Investment Income.

01 Interest on bonds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

02 Dividends on preferred stocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

03 Dividends on common stocks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

04 Interest on mortgage loans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

05 Real estate income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

06 Interest on collateral loans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

07 Cash on deposit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

08 Other invested assets

a_________________________________________________________________________________________________ 8a

b_________________________________________________________________________________________________ 8b

c_________________________________________________________________________________________________ 8c

09 Total invested assets. Add lines 8a through 8c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

10 Gross investment income. Add lines 1 through 7 and line 9. Enter result here and on page 1, line 2 . . . . . . . . . . . . . . . . . . . . 10

Part 3. Computation of Retaliatory Tax.

Foreign casualty insurers only must complete this schedule.

Use the space below to calculate your excise using the identical method and the same rate used by the state in which you are incorporated in taxing a like

Massachusetts insurance company, or its agents, if doing business to the same extent. If the computation in the state of your

incorporation is in every respect the same as your Massachusetts computation, a statement to that effect should be made . . . . . . 1