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2009 FORM INS-5, Page 2

MRS Fire Tax Account Number:

*0931101*

AFFIDAVIT AND SIGNATURE

This return is made in compliance with the provisions of 25 MRSA § 2399. The amount of all GROSS DIRECT PREMIUMS or assessments for ﬁ re

risks written by this insurer on risks located in, or received from risks resident of, the State of Maine during the year ending December 31, 2009 has

been reported. Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best

of my knowledge and belief, they are true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which

preparer has any knowledge.

Date: _________________________ Signature: ___________________________________________ Telephone #: ________________________

Must be signed by the President, Treasurer, Secretary, Chief Accounting Ofﬁ cer, or Attorney-in-fact of a reciprocal insurer.

Preparer’s

Date: _________________________ Signature: ___________________________________________ ID Number: _________________________

INSTRUCTIONS

Premium amounts to be reported: A premium is an amount paid or

associated with risks located in Maine.

payable for an insurance policy, including all fees, such as membership,

Divide a by b; this is the ratio to be used in column E for this

policy, survey, inspection, service and ﬁ nance fees, that are assessed by

particular product line.

and paid to an insurance company in consideration for an insurance policy.

A separate calculation must be made for each product line.

The instructions below provide guidance to assist in the preparation of

In the case of afﬁ liated insurance companies, a separate

this return. However, accurate and full reporting of premium amounts,

calculation must be made for each insurer.

including any applicable fees, is the responsibility of each taxpayer.

Attach a computation to your return identifying loss due to ﬁ re

Note: The ﬁ re investigation and prevention tax applies in addition to

and total loss by year for each of the ﬁ ve years used to calculate

the insurance premiums tax.

the ﬁ ve-year average.

Line 1. Amount of Premiums Allocated to Fire.

Calculate the total

Column F. Multiply the column D amount by the column E percentage

amount of premiums allocated to ﬁ re insurance for each line of business

and enter the result.

identiﬁ ed in column A.

Line 2. Total Premium.

Add column F amounts for each line of business

Column B. Enter the gross direct premiums written, less return

(line 1a. through line 1i.) and enter the sum on this line (Total amount of

premiums and premiums on policies not taken. Generally, gross

premiums allocated to ﬁ re).

direct premiums are reported on the Maine State Page of the NAIC

Line 3. Tax Liability.

Every ﬁ re insurance company or association that

Annual Statement, column 1 and related ﬁ nance and service charges

does business or collects premiums or assessments in Maine is required

are reported on Schedule T, column 8 (Finance and Service Charges

by statute to pay 1.4% of the gross direct premiums for ﬁ re risks written

not Included in Premiums).

in Maine, less the amount of all direct return premiums and all dividends

Column C. Enter dividends paid or credited to policyholders on direct

paid to policyholders on direct ﬁ re premiums.

premiums. Amounts entered must agree with column 3 of the Maine

Line 4. Less Estimated Payments.

Enter the total amount of monthly

portion of your NAIC annual statement.

estimated payments already made in 2009.

Column D. Subtract the column C amount from the column B amount

Line 5. Balance Due.

Payment must be submitted with this return.

and enter the result.

Late payments are subject to interest and penalties.

Column E. The percentages listed represent the ratio of ﬁ re losses

to total losses based on historical data. An insurer wanting to deviate

Note: Certain taxpayers with large annual tax liabilities are required

from these percentages must clearly establish alternate ratios based

to remit tax payments electronically. See Maine Rule 102 on the MRS

on its own ﬁ re loss experience. The following procedures must be

web site (select Laws & Rules) for details.

used to establish alternate ﬁ re ratios:

Beginning January 1, 2010, the interest rate is 7% per annum,

The alternate ratios must be based on the prior ﬁ ve-year average

compounded monthly. The penalty for failure to ﬁ le a return is the

ﬁ re losses.

greater of $25 or 10% of the tax due. If the return is not ﬁ led within 30

Complete the following steps to calculate the ratio for each

days after the receipt of a demand notice to ﬁ le, the penalty is 100% of

product line listed in column A:

the tax due. The penalty for failure to pay a tax liability on time is 1%,

up to a maximum of 25%, of the outstanding liability.

Calculate the ﬁ ve-year average of loss due to ﬁ re from claims

associated with risks located in Maine.

Line 6. Overpayment.

All overpayments will be refunded.

Calculate the five-year average of loss from all claims

Make check payable to :

Treasurer, State of Maine

Send return with check to:

Maine Revenue Services, P.O.Box 9120, Augusta, ME 04332-9120

Form Ins-5 - Fire Investigation And Prevention Tax Annual Reconciliation/return - 2009 Page 2

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