Form 63-23p - Premium Excise Return For Insurance Companies - 2005

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2005
Form 63-23P
Massachusetts
Premium Excise Return
Department of
for Insurance Companies
Revenue
For calendar year 2005 or taxable year beginning
2005 and ending
Name of company
Federal Identification number
Mailing address
City/Town
State
Zip
Name of treasurer
Domestic insurers, check applicable gross investment income tax rate
.01
.008
.006
.004
.002
.000
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) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ $_______________ × .0228 = ‹ 1
12 Gross investment income (from Part 2, line 10) . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ $ ______________ × applicable rate = ‹ 2
13 Fair Plan and Crime Prevention disbursement received. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 3
14 Credit recapture (enclose Schedule H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 4
15 Excise due before credits. Add lines 1 through 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 6
17 Other premiums (Fair Plan and Crime Prevention) If included in Schedule T, enclose statement . . . . . . . . . . . . . . . . . . . . . . ‹ 7
18 Total premiums. Add lines 6 and 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
19 Dividend deduction. Premiums returned or credited to policyholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 9
10 Taxable premiums. Subtract line 9 from line 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11 Tax calculation. Multiply line 10 by .0228 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 11
12 Tax computed under retaliatory provisions (enter full amount from Part 3, line 1). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 12
13 Credit recapture (enclose Schedule H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 13
14 Excise due before credits. Enter the larger of line 11 plus line 13 or line 12 plus line 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Preferred Provider Arrangements
15 Gross premiums received for coverage of covered persons residing in Massachusetts (premiums for Medicare
supplemental Coverage are excludable) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 15
16 Premiums returned or credited to policyholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 16
17 Taxable amount. Subtract line 16 from line 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
18 Tax calculation. Multiply line 17 by .0228 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 18
19 Credit recapture (enclose Schedule H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 19
20 Excise due before credits. Add lines 18 and 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Credits
21 Domestic casualty insurers only. Retaliatory surtax credit. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 21
22 Domestic casualty insurers only. Enter .015 of company’s total capital contributions in excess of the full proportionate
share in investment in the Massachusetts property and casualty initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 22
23 Credit against premium excise. Add lines 21 and 22. Enter total here, but do not exceed the amount in line 1 . . . . . . . . . . . . 23
24 Enter .10 of Massachusetts Life and Health Insurance Guaranty Association assessment paid previously . . . . . . . . . . . . . ‹ 24
25 Economic Opportunity Area Credit (enclose Schedule EOAC). Do not claim here if claimed on Form 63-29A . . . . . . . . . . . ‹ 25
26 Full Employment Credit (enclose Schedule FEC). Do not claim here if claimed on Form 63-29A . . . . . . . . . . . . . . . . . . . . . ‹ 26
27 Low-Income Housing Credit (enclose documentation). Do not claim here if claimed on Form 63-29A . . . . . . . . . . . . . . . . . ‹ 27
28 Historic Rehabilitation Credit (enclose documentation) Do not claim here if claimed on form 63-29A . . . . . . . . . . . . . . . . . . ‹ 28
29 Home Energy Efficiency Credit Do not claim here if claimed on form 63-29A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 29
30 Solar Heat Credit Do not claim here if claimed on form 63-29A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 30
31 Total credits. Add lines 23 through 30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Under the penalties of perjury, I declare to the best of my knowledge and belief, this return and enclosurers 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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