Form Rct-121-C - Gross Premium Tax - Pennsylvania Department Of Revenue - 2009 Page 2
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4RCT-121-C (I)
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1213009201
RETALIATORY WORKSHEET
SCHEDULE OF TAXES, ASSESSMENTS, LICENSES AND FEES
PENNSYLVANIA
STATE OF DOMICILE
Premium Taxes:
$
$
Fire, Casualty and Title Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ocean Marine Gross Profit Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Annuities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accident and Health Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reinsurance Assumed from Unauthorized Companies . . . . . . . . . . . . . . .
Other Taxes (Fire Marshal, Franchise, Income, etc.)
Worker’s Compensation Assessments (Not a retaliatory item for PA)
Other Assessments
Licenses and Fees (Annual Basis)
$
$
Totals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Retaliatory Payable to the PA Department of Revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANSWER THE FOLLOWING QUESTIONS
(a) How many agents are licensed to represent your company in Pennsylvania during the tax year?
(b) What are your state fees for licensing agents of similar Pennsylvania insurers?
(c) Are the fees per Item (b) imposed on the company
or the agent?
1213009201
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