Form 63-29a - Ocean Marine Profits Tax Return

Dividend Deduction Schedule

Dividends paid or credited to policyholders during the taxable year 2004. United States marine business subject to Section 29A of Chapter 63.

11 On direct business . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

12 On reinsurance assumed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

13 Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

14 Less dividends received on reinsurance paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

15 Net dividends paid or credited during 2004 on U.S. 29A Marine (page 3, line 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Federal Income Tax Deduction Schedule

Lines 6 through 12 refer to page 3, line 10.

16 Total amount of federal income tax (actual) on business year 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Give date for filing federal return __________________________.

In support of line 6, furnish a copy of your U.S. Corporation Income Tax Return, Form 1120. State the amount of underwriting gain and of investment income

that comprise “Taxable Income” in line 30 of said return. If above date indicates federal return is not yet filed, state that line 6 is estimated. Submit afore-

mentioned copy when available and the recomputation of lines 6 to 12 if necessary.

Total tax on

Part of 6 covering

17 Investment income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Normal tax

or Normal and surtax

Excess profits tax

18 Underwriting gain . . . . . . . . . . . . . . . . . . . . . . . . 8

19 Underwriting profit — all classes (Insurance Expense Exhibit, Part II) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

10 Underwriting profit (United States 29A Marine from page 3, line 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Underwriting profit — United States 29A Marine, line 10

11 Ratio:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Underwriting profit — all classes, item 9

12 Federal income tax on 2003 U.S. 29A Marine Business return. Obtain as follows: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

If ratio in line 11 is less than 100%, apply said ratio to line 8.

If ratio in line 11 exceeds 100%, the following ratio is to be applied to line 8:

Underwriting profit — United States 29A Marine, line 10

Sum of underwriting gains of all classes showing gains in Expense Exhibit. Part II

Ocean Marine Underwriting Profit Per Expense Exhibit

Complete the following schedule. The ocean marine underwriting profit as reported in the insurance expense exhibit is to be allocated to alien and United

States with no adjustment in the latter for exclusion of prior losses. Give percentages that losses incurred and expenses incurred bear to earned premiums.

Foreign

United States

Net earned premiums . . . . . . . . . . . . . .

Pct.

Net losses incurred . . . . . . . . . . . . . . . .

Net expenses incurred . . . . . . . . . . . . . .

Underwriting profit . . . . . . . . . . . . . . . . .

Foreign

United States