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FORM INS-5, Page 2

*0431101*

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Total amount of premiums allocated to fire (Enter amount from line 1) .................................................................... 2.

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Tax liability (Line 2 Multiplied by 1.4% (0. 014)) ......................................................................................................... 3.

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Less Prior Payments ................................................................................................................................................. 4.

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Balance Due (Line 3 minus line 4) ............................................................................................................................. 5.

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Overpayment to be refunded (Line 4 minus line 3) ................................................................................................... 6.

This return is made in compliance with the provisions of 25 M.R.S.A. § 2399. The amount of all GROSS DIRECT PREMIUMS or assessments for

fire risks written in the State of Maine during the year ending December 31, 2004 has been reported. Under penalties of perjury, I declare that I have

examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct and complete.

Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Telephone # _______________________

Date __________________________ Signature ____________________________________________

Must be signed by the President, Treasurer, Secretary, Chief Accounting Officer, or Attorney-in-fact of a Reciprocal Insurer.

Preparer’s

Date __________________________ Signature ____________________________________________ ID Number __________________________

INSTRUCTIONS

Premium amounts to be reported: A premium is an amount paid or

Column E. The percentages listed represent the ratio of fire losses to

payable for an insurance policy, including any fees, such as membership,

total losses based on historical data.

policy, survey, inspection, service and finance fees, that are assessed by

Column F. Multiply the column D amount by the column E percentage

and paid to an insurance company in consideration for an insurance policy.

and enter the result.

The instructions below provide guidance to assist in the preparation of

Step 2: Add column F amounts for each line of business and enter the sum

this return. However, accurate and full reporting of premium amounts,

on last line of Column F (Total amount of premiums allocated to fire).

including any applicable fees, is the responsibility of each taxpayer.

Line 3. Tax Liability.

Every fire insurance company or association that

Line 1. Amount of Premiums Allocated to Fire.

Calculate the total

does business or collects premiums or assessments in Maine is required

amount of premiums allocated to fire by following Steps 1 and 2.

by statute to pay 1.4% of the gross direct premiums for fire risks

Step 1: Calculate the amount of premiums allocated to fire for each line

written in Maine, less the amount of all direct return premiums and all

of business identified in column A.

dividends paid to policyholders on direct fire premiums.

Column B. Enter the gross direct premiums written less return premiums

Line 4. Less Prior Payments.

Enter the total amount of monthly

and premiums on policies not taken. Generally, gross direct premiums are

estimated payments already made in 2004.

reported on the Maine State Page of the NAIC Annual Statement, column

Line 5. Balance Due.

If the amount on line 3 is greater than the amount

1 and related finance and service charges are reported on Schedule T,

on line 4, enter the balance due. Payment must be submitted with this

column 8 (Finance and Service Charges not Included in Premiums).

return. Late payments are subject to interest and penalties.

Column C. Enter dividends paid or creditied to policyholders on direct

Line 6. Overpayment.

If the amount on line 4 is greater than the

premiums. Amounts entered must agree with column 3 of the Maine

amount on line 3, enter the overpayment amount. An overpayment amount

portion of your NAIC annual statement.

will be refunded.

Column D. Subtract the column C amount from the column B amount

and enter the result.

PAYMENT, INTEREST AND PENALTIES

Make check payable to :

Treasurer, State of Maine

Send return with check to:

Maine Revenue Services, P.O.Box 9120, Augusta, ME 04332-9120

The State Tax Assessor annually establishes the interest rate. The interest rate for calendar year 2005 is 0.667% per month; 8% per year,

compounded monthly.

The penalty for failure to file a return is the greater of $25 or 10% of the tax due. If the return is not filed within 30 days after the receipt of a

demand notice to file, the penalty is 100% of the tax due.

Office use only

The penalty for failure to pay a tax liability on time is 1%, up to a maximum of 25%, of the outstanding liability.