Form 63-20p - Premium Excise Return For Life Insurance Companies

Part 2. Foreign Life Premium Excise Calculation

Life Premiums

11 All new and renewal direct premiums for all policies of life insurance allocable to Massachusetts . . . . . . . . . . . . . . . . . . . . . 3 1

12 Dividends applied to:

a Purchase paid-up additions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2a

b Shorten premium paying period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2b

13 Total gross direct premiums. Add lines 1, 2a and 2b. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

14 Returned premiums but not including cash surrender values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 4

Itemized supporting schedule is required as part of line 4.

15 Dividends:

a Paid in cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 5a

b Applied in reduction of renewal premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 5b

c Left to accumulate at interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 5c

d Applied to purchase paid-up additions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 5d

e Applied to shorten premium paying period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 5e

16 Total deductions. Add lines 4 through 5e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

17 Taxable premiums. Subtract line 6 from line 3. Enter the result on page 1, line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Accident and Health Premiums

18 Total net direct premiums for insurance of property or interests in Massachusetts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 8

19 Dividend deduction. Premiums returned or credited to policyholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 9

10 Premium deduction. Gross premiums for authorized Preferred Provider arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 10

11 Total deductions. Add lines 9 and 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

12 Taxable amount. Subtract line 11 from line 8. Enter the result on page 1, line 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

13 Are net direct premiums reported in line 8?

Yes

14 Have all dividends claimed as a deduction in line 9 been included as taxable premiums in line 10 on this return or on a previous Massachusetts return?

Yes

Part 3. Computation of Retaliatory Tax

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.

a. Life computation

b. Accident and health computation