Form Ins-5 - Fire Investigation And Prevention Tax - Annual Reconciliation / Return - 2004

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FORM INS-5
MAINE REVENUE SERVICES
FIRE INVESTIGATION
00
AND PREVENTION TAX
*0431100*
ANNUAL / RECONCILIATION RETURN
MRS Insurance Account Number
NAIC Company Code
Period Covered
Due Date
January 1- December 31, 2004
March 15, 2005
Name/Address:
CHECK APPLICABLE SPACES:
Initial return
Business Name (Line 1)
Amended return
Final return
Business Name (Line 2)
Enter closing date: ___ /___ /_____
Made estimated payments
Street Address and/or Post Office Box
during the year
Change of name/address
City
State
Zip Code
COMPUTATION OF TAX ON FIRE PREMIUMS
1.
Amount of premiums allocated to fire (See instructions)
A
B
C
D
E
F
Line of Business
Gross Premiums
Dividends Paid
Total Net
% of Premiums
Amount of Premiums
(Less Return Premiums
or Credited on
Taxable
Allocated to Fire
Allocated to Fire
and Premiums on
Direct Business
Premiums
(column D x column E)
Policies not Taken)
,
,
$
.00
Fire .......................................... $ _______________ $ _________________ $ __________________
100.00%
,
,
$
.00
Inland Marine ........................... $ _______________ $ _________________ $ __________________
15.00%
,
,
$
.00
Aircraft Physical Damage ...... $ _______________ $ _________________ $ __________________
Actual
Auto Physical Damage:
Comprehensive – Full Coverage
,
,
.00
$
Private ............................ $ _______________ $ _________________ $ __________________
4.60%
,
,
.00
$
Commercial ..................... $ _______________ $ _________________ $ __________________
14.30%
Comprehensive – All Deductibles:
,
,
$
.00
Private ............................ $ _______________ $ _________________ $ __________________
5.80%
,
,
$
.00
Commercial ..................... $ _______________ $ _________________ $ __________________
17.98%
Fire and Theft:
,
,
$
.00
Private ............................ $ _______________ $ _________________ $ __________________
47.00%
,
,
.00
$
Commercial ..................... $ _______________ $ _________________ $ __________________
50.00%
Fire, Theft and Miscellaneous:
,
,
$
.00
Private ............................ $ _______________ $ _________________ $ __________________
10.60%
,
,
$
.00
Commercial ..................... $ _______________ $ _________________ $ __________________
42.90%
,
,
$
.00
Home Owners Policies ............ $ _______________ $ _________________ $ __________________
55.70%
,
,
$
.00
Commercial Multiple Peril ....... $ _______________ $ _________________ $ __________________
49.90%
,
,
$
.00
Any Other Fire related ............ $ _______________ $ _________________ $ __________________
Actual
,
,
$
.00
1.
Total amount of premiums allocated to fire ........................................................................................................... 1.
INS-5 Rev. 11/04

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