Form Ins-5 - Fire Investigation And Prevention Tax Annual Reconciliation/return - 2007

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MAINE REVENUE SERVICES
FORM INS-5
00
FIRE INVESTIGATION AND PREVENTION TAX
07
*0731100*
ANNUAL RECONCILIATION / RETURN
MRS Insurance Account Number
NAIC Company
Period Covered
Due Date
-
January 1- December 31, 2007
March 15, 2008
Name/Address:
CHECK ALL THAT APPLY:
Initial return
Business Name (Line 1)
Amended return
Final return
Business Name (Line 2)
Enter closing date: ___ /___ /___
Street Address and/or Post Office Box
Change of name/address
City
State
ZIP Code
COMPUTATION OF TAX ON FIRE PREMIUMS
1.
Amount of premiums allocated to fire (See instructions)
A
B
C
D
E
F
Line of Business
Gross Premiums
Dividends Paid
Total Net
% of Premiums
Amount of Premiums
(Less Return Premiums
or Credited on
Taxable
Allocated to Fire
Allocated to Fire
and Premiums on
Direct Business
Premiums
(column D x column E)
Policies not Taken)
,
,
$
.00
1a. Fire . ....................... $ _________________ $ ________________ $ _________________
100.00%
,
,
$
.00
1b. Inland Marine ........ $ _________________ $ ________________ $ _________________
15.00%
1c. Aircraft Physical
,
,
$
.00
Damage . ............. $ _________________ $ ________________ $ _________________ Actual*
Auto Physical Damage:
Comprehensive – Full Coverage
,
,
$
.00
1d.Private . ................... $ _________________ $ ________________ $ _________________
4.60%
,
,
$
.00
1e. Commercial . .......... $ _________________ $ ________________ $ _________________
14.30%
Comprehensive – All Deductibles:
,
,
$
.00
1f. Private . ................... $ _________________ $ ________________ $ _________________
5.80%
,
,
$
.00
1g. Commercial . .......... $ _________________ $ ________________ $ _________________
17.98%
Fire and Theft:
,
,
$
.00
1h. Private . .................. $ _________________ $ ________________ $ _________________
47.00%
,
,
$
.00
1i. Commercial ............ $ _________________ $ ________________ $ _________________
50.00%
Fire, Theft and Miscellaneous:
,
,
$
.00
1j. Private .................... $ _________________ $ ________________ $ _________________
10.60%
,
,
$
.00
1k Commercial ........... $ _________________ $ ________________ $ _________________
42.90%
,
,
$
.00
1l. Homeowners Policies $ _______________ $ ________________ $ _________________
55.70%
,
,
$
.00
1m. Commercial Multiple Peril $ ___________ $ ________________ $ _________________
49.90%
,
,
$
.00
1n. Any Other Fire related $ _ _____________ $ ________________ $ _________________ 100.00%
,
,
$
.00
1o. Total amount of premiums allocated to fire .................................................................................................1o.
* Line 1c only: Enter in column F the premiums actually received on fire risks located in Maine
Rev. 10/07

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