IB-83
2006 Gross Premium Tax Return
I-B
Web
Risk Purchasing Group
Insurance
5-07
North Carolina Department of Revenue
Legal Name (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
Fill in circle if applicable:
Payment has been made through
Mailing Address
electronic funds transfer (EFT)
City
State
Zip Code
Federal Employer ID Number
Name and title of person responsible for the computation and filing of this return
Phone Number (Include area code)
(
)
Computation of Gross Premium Tax
.
,
,
1.
N.C. gross premiums on insurance purchased during calendar year
00
1.
from surplus agents or brokers
.
,
,
2.
Gross premium tax
00
2.
Multiply Line 1 by 5.0% (.05)
.
,
,
3.
N.C. gross premiums on insurance purchased during calendar year
00
3.
from licensed insurance companies
.
,
,
4.
Gross premium tax
00
4.
Multiply Line 3 by 1.9% (.019)
.
,
,
5.
Gross premium tax due for the risk purchasing group
00
5.
Line 2 plus Line 4
.
,
,
00
6.
6.
Tax Credit (Attach Form NC-478)
.
,
,
7.
Gross premium tax due
00
7.
Line 5 minus Line 6
.
,
,
8.
Installments paid by: (Fill in applicable circle)
00
8.
Surplus lines agents or brokers
Licensed insurance companies
Risk purchasing group
.
,
,
$
9.
Balance of gross premium tax due
00
9.
Line 7 minus Line 8, but not less than zero. If less than zero, enter amount on Line 10
.
,
,
00
10.
10.
Overpayment
.
,
,
00
11.
11.
Amount of Line 10 applied to first installment of 2007 gross premium tax
.
,
,
12.
Gross premium tax to be refunded
00
12.
Line 10 minus Line 11
If tax due is not paid by the risk purchasing group you must attach a schedule showing the name of each insurer and
each type of insurer from which insurance has been purchased. A statement from each insurer listed certifying that
the tax due as calculated on this return is being reported and paid by the insurer must also be attached.
Signature:
Title:
Date:
I certify that, to the best of my knowledge, this return is accurate and complete.
Make check or money order in U.S. currency payable to the N.C. Department of Revenue.
This return is due by March 15th.
MAIL TO: North Carolina Department of Revenue, Insurance Premium Tax Unit,
P.O. Box 25000, Raleigh, North Carolina 27640-0300