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07 FORM INS-5, Page 2

*0731101*

MRS Insurance Account Number:

.00

Total amount of premiums allocated to fire (Enter amount from line 1o) ................................................. 2.

.00

Tax liability (line 2 multiplied by 1.4% (0. 014)) . ....................................................................................... 3.

.00

Less estimated payments . ....................................................................................................................... 4.

.00

Balance due (If line 3 is greater than line 4, line 3 minus line 4) ............................................................. 5.

.00

Overpayment to be refunded (If line 4 is greater than line 3, line 4 minus line 3) ................................... 6.

AFFIDAVIT AND SIGNATURE

This return is made in compliance with the provisions of 25 M.R.S.A. § 2399. The amount of all GROSS DIRECT PREMIUMS or assessments for fire

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, 2007 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 Officer, 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 payable

Calculate the five-year average of loss from all claims associated

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

with risks located in Maine.

inspection, service and finance fees, that are assessed by and paid to an

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

insurance company in consideration for an insurance policy. The instructions

particular product line.

below provide guidance to assist in the preparation of this return. However,

A separate calculation must be made for each product line.

accurate and full reporting of premium amounts, including any applicable fees,

In the case of affiliated insurance companies, a separate calculation

is the responsibility of each taxpayer.

must be made for each insurer.

3. Attach a computation to your return identifying loss due to fire and

Note: The fire investigation and prevention tax applies in addition to

total loss by year for each of the five years used to calculate the

the insurance premiums tax.

five-year average.

Line 1. Amount of Premiums Allocated to Fire. Calculate the total amount

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

of premiums allocated to fire by following Steps 1 and 2 below.

and enter the result.

Step 1: Calculate the amount of premiums allocated to fire for each line of

Step 2: Add column F amounts for each line of business and enter the sum

business identified in column A.

on line 1o and line 2 (Total amount of premiums allocated to fire).

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

Line 3. Tax Liability. Every fire insurance company or association that does

and premiums on policies not taken. Generally, gross direct premiums are

business or collects premiums or assessments in Maine is required by statute

reported on the Maine State Page of the NAIC Annual Statement, column

to pay 1.4% of the gross direct premiums for fire risks written in Maine, less

1 and related finance and service charges are reported on Schedule T,

the amount of all direct return premiums and all dividends paid to policyholders

column 8 (Finance and Service Charges not Included in Premiums).

on direct fire premiums.

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

Line 4. Less

EstimatedPayments.

Enter the total amount of monthly

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

estimated payments already made in 2007.

portion of your NAIC annual statement.

Line 5. Balance Due.

Payment must be submitted with this

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

and enter the result.

return. Late payments are subject to interest and penalties.

Column E. The percentages listed represent the ratio of fire losses to

Note: Certain taxpayers with large annual tax liabilities are required to

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

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

these percentages must clearly establish alternate ratios based on its own

site (select Laws & Rules) for details.

fire loss experience. The following procedures must be used to establish

Beginning January 1, 2008, the interest rate is 12% per annum, compounded

alternate fire ratios:

monthly. The penalty for failure to file a return is the greater of $25 or 10%

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

of the tax due. If the return is not filed within 30 days after the receipt of a

fire losses.

demand notice to file, the penalty is 100% of the tax due. The penalty for

Complete the following steps to calculate the ratio for each product

failure to pay a tax liability on time is 1%, up to a maximum of 25%, of the

line listed in column A:

outstanding liability.

Calculate the five-year average of loss due to fire from claims

Line 6. Overpayment. All overpayments will be refunded.

associated with risks located in Maine

Make check payable to :

Treasurer, State of Maine

Send return with check to:

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

Office

use only

Form Ins-5 - Fire Investigation And Prevention Tax Annual Reconciliation/return - 2007 Page 2

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