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

Payments

28 2004 overpayment applied to 2005 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 28

29 2005 Massachusetts estimated tax payments (do not include amount from line 28). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 29

30 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 30

31 Total payments. Add lines 28 through 30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Refund or balance due

32 Amount overpaid. Subtract line 27 from line 31 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

33 Amount overpaid to be credited to 2006 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 33

34 Amount overpaid to be refunded. Subtract line 33 from line 32 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 34

35 Balance due. Subtract line 31 from line 27 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

36 M-2220 penalty ‹ $ ______________________ ; Other penalties ‹ $ ______________________. . . . . . . . . Total penalty 36

37 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 37

38 Total payment due at time of filing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 38

Part 1. Domestic Life Premium Excise Calculation

Life insurance

Accident and health insurance

Jurisdictions where no

Massachusetts

insurance excise paid

Massachusetts

insurance excise paid

11 All new and renewal (direct) premiums for

‹

Massachusetts residents . . . . . . . . . . . . . . . . . . 1

12 Dividends applied to:

‹

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

‹

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

13 Total. Add lines 1 through 2b . . . . . . . . . . . . . . . 3

Deductions.

Include only what has been returned as receipts on this return or on a previous return.

14 Returned premiums but not including cash

‹

surrender values (enclose schedule). . . . . . . . . 4

15 Premiums for company employees’ group

life and accident and health plans if included

‹

in line 1* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

16 Gross premiums for authorized preferred

‹

provider arrangements . . . . . . . . . . . . . . . . . . . . 6

17 Dividends:

‹

a Paid in cash. . . . . . . . . . . . . . . . . . . . . . . . . 7a

‹

b Applied in reduction of renewal premiums 7b

‹

c Left to accumulate at interest . . . . . . . . . . . 7c

‹

d Applied to purchase paid-up additions . . . . 7d

‹

e Applied to shorten premium paying period 7e

18 Total deductions. Add lines 4 through 7e. . . . . . 8

19 Amount taxable. Subtract line 8 from line 3. . . . 9

10 Total life amount taxable. Add line 9, columns a and b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

11 Total accident and health amount taxable. Add line 9, columns c and d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

*Premiums under the company employees’ group plans for annuity consideration and retirement benefits shall not be deducted.