Tax Disclosure Report Form - Domestic Property And Casualty Insurance Companies - 2009

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FILING FOR MARCH 1, 2009

FEDERAL IDENTIFICATION

NO. _____________________

The Commonwealth of Massachusetts

William Francis Galvin

Secretary of the Commonwealth

One Ashburton Place, Boston, Massachusetts 02108-1512

TAX DISCLOSURE REPORT

Domestic Property and Casualty Insurance Companies

1. Exact name of insurance company: _____________________________________________________________________________

2. Location, including street address, of the insurance company’s principal office: ___________________________________________

__________________________________________________________________________________________________________

I, _________________________________________, the undersigned *Treasurer / *Assistant Treasurer, of the above-named

company, do hereby certify that all the information contained herein is true and correct as of the date shown below.

SIGNED UNDER THE PENALTIES OF PERJURY, this __________ day of________________________________ , 20 ___________.

__________________________________________________________________________________ , *Treasurer / *Assistant Treasurer

(signature)

TAX DISCLOSURE REPORT

Domestic Property and Casualty Insurance Companies

3. Tax year for which the report is filed: .............................................................................................................. _____________________

4. Gross receipts or sales: ................................................................................................................................... $ _____________________

5. Premiums and income taxable in Massachusetts: ........................................................................................... $ _____________________

6. Total Massachusetts excise or tax due: ............................................................................................................ $ _____________________

7. Set forth the amount of each tax credit taken: _____________________________________________________________________

*Delete the inapplicable words.

Note: You may furnish supplemental information in accordance with M.G.L. Ch 62C, s.83(j) on separate 8

x 11 sheets of white bond paper.

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tdrdpcic 2/2/09