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Form 63-20-23

2001

Premium Excise Return for

Massachusetts

Foreign Life Insurance Companies on

Department of

Life, Accident and Health Business

Revenue

For calendar year 2001 or taxable year beginning

2001 and ending

Name of company

Federal Identification number

❿

Mailing address

DOR use only

Name of treasurer

Organized under the laws of

Has the federal government changed your taxable income for any prior year which has not yet been reported to Massachusetts?

Yes

No.

Computation of Excise.

Attach a copy of Schedule T of NAIC Annual Statement.

Income and Excise Before Credits

Use whole dollar method

❿ $ ________________ × .02 (2%) =

❿ 1

11 Taxable life premiums (Part I, line 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12 Retaliatory computation (Part II, column A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 2

13 Applicable measure (enter the larger of line 1 or line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

14 Taxable accident and health premiums (Part I, line 12) . . . . . . . . . . . . . . . . . . . . . ❿ $ ________________ × .02 (2%) =

❿ 4

15 Retaliatory computation (Part II, column B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 5

16 Applicable measure (enter the larger of line 4 or line 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

17 Economic Opportunity Area Credit Recapture (attach Schedule H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 7

18 Excise before credits. Add lines 3, 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Credits

19 Enter 1.5% of company’s capital contribution in excess of your full proportionate share in the Massachusetts life

insurance company community investment initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 9

10 Enter 10% of Massachusetts Life and Health Insurance Guaranty Association assessment paid in the prior years. . . . . . . ❿ 10

11 Economic Opportunity Area Credit (attach Schedule EOA). If this credit was claimed on Form 176-I, do not claim here. . . ❿ 11

12 Full Employment Credit (attach Schedule FEC). If this credit was claimed on Form 176-I, do not claim it on this form . . . . ❿ 12

Excise After Credits

13 Excise due before voluntary contribution. Subtract the total of lines 9 through 12 from line 8. Not less than “0”. . . . . . . . . . . . 13

14 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 14

15 Excise plus voluntary contribution. Add lines 13 and 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 15

Payments

16 2000 overpayment applied to 2001 estimated tax. . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 16

17 2001 Massachusetts estimated tax payments (do not include amount from line 16) ❿ 17

18 Payments made with extension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 18

19 Total payments. Add lines 16 through 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Refund or Balance Due

20 Amount overpaid. Subtract line 15 from line 19. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

21 Amount overpaid to be credited to 2002 estimated tax . . . . . . . . . . . . . . . . . . . . . . . ❿ 21

22 Amount overpaid to be refunded. Subtract line 21 from line 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 22

23 Balance due. Subtract line 19 from line 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

24 M-2220 penalty ❿ $ ______________________ ; other penalties ❿ $ ______________________. . . . . . . . . Total penalty 24

25 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 25

26 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 26

Declaration

Under the penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my

knowledge and belief, it is true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which he/she has

knowledge.

Signature of appropriate corporate officer (see instructions)

Social Security number

Telephone number

Date

Individual or firm signature of preparer

Employee Identification number

Address

Date