Form Tc-49 - Schedule A

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TC-49A_1
Rev. 7/11
49003
Utah State Tax Commission
210 N 1950 W • Salt Lake City, UT 84134 • tax.utah.gov
Bus. Name:
Acct. #:
TC-49 Schedule A
Tax Period:
Page 1 of 2
Annual Report Totals
Include an 8 1/2” x 11” copy of the Utah business page and/or Schedule T of the Annual Report with this return.
•
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1. Life insurance companies: Enter the total from the Utah business page ............................................
1 _________________ .
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2. Property and casualty insurance companies: Enter the total from the Utah business page ...............
2 _________________ .
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3. Other insurance companies: Enter the total amount from your annual statement of premiums written in Utah
3 _________________ .
Premiums received from direct business in Utah
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4. Life/variable life insurance (see instructions) ......................................................................................
4 _________________ .
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5. Remaining variable life insurance (attach schedule of all variable life insurance premiums)..............
5 _________________ .
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6. Annuity................................................................................................................................................
6 _________________ .
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7. Health care..........................................................................................................................................
7 _________________ .
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8. Other disability ....................................................................................................................................
8 _________________ .
•
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9. Fire including allied lines.....................................................................................................................
9 _________________ .
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10. Other than fire including allied lines ....................................................................................................
10 _________________ .
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11. Motor vehicle liability, personal injury protection, uninsured motorist .................................................
11 _________________ .
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12. Motor vehicle physical damage (non-fire portion) ...............................................................................
12 _________________ .
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13. Motor vehicle damage (fire portion) ....................................................................................................
13 _________________ .
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14. Ocean marine .....................................................................................................................................
14 _________________ .
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15. Other (specify): ____________________________________............
15 _________________ .
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16. Interest and service charges...............................................................................................................
16 _________________ .
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17. Base premiums (add lines 4 through 16) ..........................................................................................
17 _________________ .
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18. Title insurance.....................................................................................................................................
18 _________________ .
Workers’ Compensation
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19. All agencies.........................................................................................................................................
19 _________________ .
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20. Deductibles (see instructions).............................................................................................................
20 _________________ .
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21. Add line 19 and line 20 .......................................................................................................................
21 _________________ .
22. Total premiums (add lines 17, 18 and 21)
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Should agree with line 1, 2 or 3 above. See instructions if amounts do not agree. .............................
22 _________________ .
Continued next page.

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