Form Ins-4 - Insurance Premiums Tax Return - 2005 Page 3
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4SCHEDULE 1
FORM INS-4
DEDUCTIONS BY PREMIUM TYPE
AND DOLLAR AMOUNT
For Form INS-4, Part A, lines 2 - 6
MRS Insurance
2005
Taxpayer Name ____________________________ Account Number _________________________ Tax Year ______________
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
Accident & Health
Life
Front End Annuity
Property & Casualty
Title
Workers
Other
Totals
Considerations
(Exclude Title &
Comp
Workers Comp)
1.
Direct
Return
Premiums
∗
2.
Dividends
Paid
∗
3.
Qualified
Pension
Plans
∗
4.
Other
Deductions
5.
Totals
∗
Lines 2 through 4 do not apply to Risk Retention Groups.
Enter line 1, column H amount on Form INS-4, line 2.
Enter line 2, column H amount on Form INS-4, line 3.
Enter line 3, column H amount on Form INS-4, line 4.
Enter line 4, column H amount on Form INS-4, line 5. Attach all documentation to support amount claimed.
SCHEDULE 2
RETALIATORY TAX
For Form INS-4, Part B
Note: This Schedule must be completed by all insurers not incorporated in Maine.
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
Accident & Health
Life
Annuity
Property & Casualty
Title
Workers
Other
Totals
(Excludes Title)
Comp
1.
Gross
Premiums
2.
Allowable
Deductions
3.
Net Taxable
Premiums
4.
Tax Rate -
State of
Incorporation
∗
5.
Annual Tax
Due
∗
If minimum tax applies, enter mimimum tax. Do not include fees. (See Schedule 2 Instructions)
Enter line 1, column H amount on Form INS-4, line 12.
Enter line 2, column H amount on Form INS-4, line 13. Attach all documentation to support amount claimed.
Enter line 3, column H amount on Form INS-4, line 14.
Enter line 5, column H amount on Form INS-4, line 15.
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