Form Ip-1 - Vermont Insurance Premium Tax Return - 2010 Page 2
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2Life, Accident & Health and Annuity - Computation of Insurance Premium Tax on all business reported on Schedule T by Life, Accident & Health and
Annuity Companies. Please refer to the Form IP-1 instructions to ensure the tax return is completed accurately.
Column A
Column B
State of Domicile
State of Vermont
19. Gross direct life premiums collected during the year.
19.
20. Vermont Domiciled companies - Gross direct life premiums written and
collected which are not taxed by other state(s).
20.
21. Gross direct accident and health premiums collected during the year
21.
22. Total Life and Accident & Health Premiums
22.
23. Life dividends applied on renewal premiums
23.
24. Life dividends paid in cash
24.
25. Life dividends left to accumulate
25.
26. Dividends paid to policyholders on accident and health policies
26.
27. Other dividend deductions (List or attach a schedule and enter in the total
from schedule)
27.
28. Total Allowable Deductions
28.
29. Net Taxable Premiums
29.
30. Life and Accident & Health tax liability at rate of __________%
(Insert state of domicile percentage)
30.
31. Life and Accident & Health tax liability at rate of 2% for Vermont
31.
32. Gross annuity considerations during the year
32.
33. Allowable annuity deductions (List or attach a schedule and enter the
total from schedule)
33.
34. Taxable Annuity Considerations
34.
35. Annuity tax liability rate of ___________% (0% for Vermont)
35.
36. Life, Accident and Health & Annuity Premium Tax
36.
37. Credit for payments to the Vermont Life & Health Insurance Guaranty
Association
37.
38. Net Premium Tax Due
38.
GENERAL INSTRUCTIONS
A. Print or type the complete company name and address.
B. Enter the date the company was organized in the state of domicile.
C. Record the NAIC#.
D. Record the State in which the company is domiciled.
E. Record the Federal ID#
F. Record the date this company was first licensed to conduct business in Vermont.
G. Fill in the “Signature Required” section completely and accurately.
To be considered a “complete” return, please attach all schedules and relevant documents.
For assistance, call the Vermont Department of Taxes, Miscellaneous Tax Division, at (802) 828-2551, option 4.
Form IP-1
Rev. 12/10
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