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

Excise After Credits

32 Excise due before voluntary contribution. Subtract line 31 from line 5, 14 or 20, whichever is applicable. Not less than “0” . . . 32

33 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 33

34 Total excise plus voluntary contribution. Add lines 32 and 33 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 34

Payments

35 2004 overpayment applied to 2005 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 35

36 2005 Massachusetts estimated tax payments (do not include amount from line 35) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 36

37 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 37

38 Total payments. Add lines 35 through 37 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Refund or Balance Due

39 Amount overpaid. Subtract line 34 from line 38 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

40 Amount overpaid to be credited to 2006 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 40

41 Amount overpaid to be refunded. Subtract line 40 from line 39 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 41

42 Balance due. Subtract line 38 from line 34 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

43 M-2220 penalty ‹¤$_______________________ ; Other penalties ‹ $ ______________________. . . . . . . . . Total penalty 43

44 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 44

45 Total payment due at time of filing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 45

Part 1. Premium Excise.

Domestic casualty insurers only must complete this schedule.

01 Total of all net direct premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 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.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‹ 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 NAIC Annual Statement, Form 2, Underwriting and Investment Exhibit, part I, col. 8, or Form 9, Operations and Investment Exhibit, part I, col. 8, for the

taxable year.

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