Form Ip-1 - Insurance Premium Tax Return - 2006 (Page 2 of 2) in pdf

COMPUTATION OF LIFE, ACCIDENT & HEALTH AND ANNUITY

State of Incorporation

State of Vermont

INSURANCE PREMIUM TAX

Basis

Use Lines 17-35 for these types of Insurance only.

17. Gross direct life premiums collected during the year.

17.

18. If a Vermont company, indicate gross direct life premiums written

& collected and not taxed by the other states.

18.

19. Gross direct accident & health premiums collected during the year

19.

20. TOTAL PREMIUMS (Add Lines 17 - 19)

20.

21. Life dividends applied on renewal premiums

21.

22. Life dividends paid in cash

22.

23. Life dividends left to accumulate

23.

24. Dividends paid to policyholders on Accident & Health policies

24.

25. Other deductions (please specify)

25.

26. TOTAL DEDUCTIONS (Add Lines 21 - 25)

26.

27. NET TAXABLE PREMIUMS (Subtract Line 26 from Line 20)

27.

28. Tax rate of __________% (2% for Vermont)

28.

29. Gross annuity premium & considerations during the year

29.

30. Annuity deductions (please specify)

30.

31. TAXABLE ANNUITY PREMIUMS & CONSIDERATIONS

(Subtract Line 30 from Line 29)

31.

32. Tax rate of ___________% (0% for Vermont)

32.

33. LIFE, ACCIDENT & HEALTH and ANNUITY PREMIUM TAX:

(Add Lines 28 and 32)

33.

34. Credit for payments to the Vermont Life & Health

Insurance Guaranty Association

34.

35. NET PREMIUM TAX DUE (Subtract Line 34 from Line 33 enter on Line 10)

(Do not carry excess credit to Line 10)

35.

Instructions:

1. Payments to the Vermont Life & Health Insurance Guaranty Association are deductible as a credit against your Vermont Life, Accident & Health

and Annuity Insurance Premium Tax liability [8 V.S.A., § 4167 (b)]. This is the specific provision for credit.

2. Payments to the Vermont Property and Casualty Insurance Association are not deductible as a credit against your Vermont Insurance Premium Tax

liability (8 V.S.A., §3611 9). There is no provision for credit.

3. All payments to the Vermont Life & Health Insurance Guaranty Association are allowable in the computation of the credit including the $25.00

Class A assessment.

4. The credit applies up to the tax liability as shown on Line 33. Refunds are not due on excess credit over the tax liability on Line 33.

5. The credit is 20% of the payment each year starting in the year following the year the payment was made to the association.

6. Please submit, as proof of payment, a copy of your cancelled check with the return in which the credit is first claimed.

7. Copies of the Certificates of Contribution(s) used to compute the credit must accompany the return. There can be several certificates in a given year, one

for each impaired company.

8. Attach schedule of computation of credit. For assistance call (802) 828-2310.

9. The disclosure of your S.S. or FID # is mandatory, authorized by 42 U.S.C. 405 (c) (2) (C) and used to identify taxpayers affected by Vermont tax laws.

10. Corporations organized under N.Y. law are required to attach a copy of their N.Y. Corp. Franchise Tax Return with this return.