Form Ins-4 - Insurance Premiums Tax Return - 2005
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4FORM INS-4
MAINE REVENUE SERVICES
2005
2005
00
INSURANCE PREMIUMS TAX RETURN
*0530000*
MRS Insurance Account Number
NAIC Company Code
Period Covered
Due Date
January 1- December 31, 2005
March 15, 2006
Name/Address:
CHECK ALL THAT APPLY:
Business Name (Line 1)
Initial return
Amended return
Business Name (Line 2)
Final return
Risk Retention Group
Street Address and/or Post Office Box
Domiciled in Maine
Change of name/address
City
State
Zip Code
,
,
,
$
.00
Enter total assets reported on annual statement: .................................................
Part A – Maine Tax Computation
Premiums:
,
,
.00
1a.
Accident and Health Premiums ................................................................................................................... 1a.
,
,
.00
1b.
Life Premiums .............................................................................................................................................. 1b.
,
,
.00
1c.
Property and Casualty Premiums (other than Workers’ Compensation Premiums) ..................................... 1c.
,
,
.00
1d.
Workers’ Compensation Premiums ............................................................................................................. 1d.
,
,
.00
1e.
Title insurance premiums ............................................................................................................................. 1e.
,
,
.00
1f.
Total Gross Direct Premiums (Add lines 1a through 1e) ........................................................................... 1f.
,
,
.00
1g.
Annuity Considerations received this tax year (See Instructions) ............................................................... 1g.
,
,
.00
1h.
Annuity Considerations received prior to January 1, 1999 (See Instructions) ............................................ 1h.
,
,
.00
Total Annuity Considerations
1i.
(Add lines 1g and 1h) ......................................................................... 1i.
,
,
.00
Total Premiums
1j.
(Add lines 1f and 1i) .................................................................................................... 1j.
Deductions:
,
,
.00
2.
Direct return premiums or deposits thereon (Schedule 1, line 1, column H) ................................................ 2.
,
,
.00
3.
Dividends paid, credited or allowed on direct premiums (Schedule 1, line 2, column H) ............................. 3.
,
,
.00
4.
Premiums exempt under qualified pension plans (Schedule 1, line 3, column H) ........................................ 4.
,
,
.00
.
5.
Other Deductions (Schedule 1, line 4, column H) ........................................................................................ 5
,
,
.00
Total Deductions
6.
(Add lines 2, 3, 4 and 5. Total should equal Schedule 1, line 5, column H) ................... 6.
Tax :
7.
Total net taxable premiums ( Line 1j minus line
,
,
.00
6) ................................................................. 7.
8.
Net premiums on qualified group disability poli-
cies written by large domestic insurer taxable at
,
,
,
,
.00
.00
2.55% ........................................................ 8a.
X 2.55%.. 8b.
9.
Net premiums on qualified group disability & cer-
,
,
,
,
.00
.00
tified long-term care policies Taxable at 1% 9a.
X 1.00%.. 9b.
10. Net premiums taxable at 2% (Line 7 less Lines
,
,
,
,
.00
.00
8a and 9a) ............................................... 10a.
X 2.00% .10b.
,
,
$
11.
Total Tax
(Total of lines 8b, 9b and 10b. Cannot be less than zero.) ................................................. 11.
.00
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