Form Rct-121 - Gross Premium Tax - 2007 Page 3

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RCT-121
Page 3
ATTACH COPY OF PENNSYLVANIA BUSINESS PAGE AND SCHEDULE T OF THE ANNUAL REPORT FILED WITH THE PENNSYLVANIA INSURANCE
DEPARTMENT.
Fire, Casualty and Title Insurers (Do not include Ocean Marine Premiums)
1.
Gross Direct Premiums Received Less Cancellations and Premiums Returned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
2.
Less: Extraordinary Medical Benefit Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.
Less: Dividends to Policyholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.
Less: Other deductions (Attach Schedule.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.
Premiums Taxable (Line 1 minus Lines 2, 3 and 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurers
6.
Gross Life Premiums (Direct Writing Basis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
7.
Less: Dividends to Policyholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.
Less: Other deductions (Attach Schedule.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9.
Life Premiums Taxable (Line 6 Minus Lines 7 and 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10. Gross Direct Accident and Health Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
11.
Less: Dividends to Policyholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12. Less: Other deductions (Attach Schedule.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13. Accident and Health Premiums Taxable (Line 10 Minus Lines 11 and 12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14. Total Taxable Premiums (Line 5 Plus Lines 9 and 13) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15. Tax (Line 14 times .02) [Domestic Life, Fire & Casualty and Foreign Casualty & Fire; Enter this amount on Page 1, Column A - 2%] . . .
(Whole Dollars Only)
16. Retaliatory (From Page 2 of Report) [Foreign Casualty and Foreign Fire; Enter this amount on Page 1, Column A - Retaliatory] . . . . . . .
(Whole Dollars Only)
17. Total (Line 15 Plus Line 16) [Foreign Life and Foreign Title; Enter this amount on Page 1, Column A - 2% & Retaliatory] . . . . . . . . . . . . .
(Whole Dollars Only)
18. Less: Tax Credits (See Instructions ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19. Less: Tentative Payments (Domestic Life, Fire & Casualty, Foreign Life & Title) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20. Amount due Commonwealth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
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