Form Rct-121 - Gross Premium Tax - 2007 Page 2

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RCT-121
2
Page
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SCHEDULE OF TAXES, ASSESSMENTS, LICENSES AND FEES
PENNSYLVANIA
STATE OF INCORPORATION
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
ATTACH A COPY OF PENNSYLVANIA BUSINESS PAGE AND SCHEDULE T OF THE ANNUAL REPORT FILED
WITH THE PENNSYLVANIA INSURANCE DEPARTMENT AND ALL OTHER DOCUMENTATION TO THIS PAGE.
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?
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