Form Ins-4 - Insurance Premiums Tax Return - 2008
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3MAINE REVENUE SERVICES
FORM INS-4
2008
00
INSURANCE PREMIUMS TAX RETURN
*0830000*
MRS Insurance Premiums Tax Account Number
NAIC ID Number
Period Covered
Due Date
January 1- December 31, 2008
March 15, 2009
-
Name/Address:
CHECK ALL THAT APPLY:
Business Name (Line 1)
Initial return
Amended return
Business Name (Line 2)
Final return
Risk Retention Group
Street Address and/or Post Offi ce Box
Domiciled in Maine
Change of name/address
City
State
ZIP Code
,
,
,
$
.00
Enter total assets reported on annual statement: .................................................
Part A – Maine Tax Computation
Premiums:
.00
,
,
1a.
Accident and Health Premiums .....................................................................................................................1a.
.00
,
,
1b.
Life Premiums ...............................................................................................................................................1b.
,
,
.00
1c.
Property and Casualty Premiums (other than Workers’ Compensation Premiums) ....................................1c.
.00
,
,
1d.
Workers’ Compensation Premiums ...............................................................................................................1d.
.00
,
,
1e.
Title Insurance Premiums .............................................................................................................................1e.
,
,
.00
1f.
Total Gross Direct Premiums (Add lines 1a through 1e) ...........................................................................1f.
.00
,
,
1g.
Annuity Considerations received this tax year (See Instructions) ...............................................................1g.
,
,
.00
1h.
Annuity Considerations received prior to January 1, 1999 taxable this year (See Instructions) .................1h.
.00
,
,
Total Annuity Considerations
1i.
(Add lines 1g and 1h) ..........................................................................1i.
.00
,
,
Total Premiums
1j.
(Add lines 1f and 1i) .....................................................................................................1j.
Deductions:
,
,
.00
2.
Direct return premiums or deposits thereon (Schedule 1, line 1, column H) ................................................2.
.00
,
,
3.
Dividends paid, credited or allowed on direct premiums (Schedule 1, line 2, column H) .............................3.
.00
,
,
4.
Premiums exempt under qualifi ed pension plans (Schedule 1, line 3, column H) ........................................4.
.00
,
,
.
5.
Other Deductions (Schedule 1, line 4, column H) .........................................................................................5
.00
,
,
Total Deductions
6.
(Add lines 2, 3, 4 and 5. Total should equal Schedule 1, line 5, column H) ................6.
Tax :
7.
Total net taxable premiums ( Line 1j minus line
,
,
6) ..................................................................... 7.
8.
Net premiums on qualified group disability
policies written by large domestic insurer taxable
,
,
,
,
at 2.55% ........................................................ 8a.
.00
X 2.55%
8b.
9.
Net premiums on qualifi ed group disability &
certifi ed long-term care policies taxable at 1%.
,
,
,
,
..................................................................... 9a
X 1.00%
9b.
.00
10. Net premiums taxable at 2% (Line 7 less Lines
,
,
.00
,
,
8a and 9a) .................................................. 10a.
X 2.00% 10b.
,
,
$
. Total Tax
.00
11
(Total of lines 8b, 9b and 10b. Cannot be less than zero.) .................................................11.
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