Form Ld-T - Annual Report Of Premiums,taxes And Fees Of Foreign Life And Accident And Health Insurance Companies - 2011 Page 6

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ARKANSAS INSURANCE DEPARTMENT
2011 FORM AID AC LD-T
ACCOUNTING DIVISION
ACCOUNTING DIVISION
___REFUND DUE
1200 WEST THIRD STREET
DUE MARCH 1, 2012
LITTLE ROCK, AR 72201-1904
PHONE: (501) 371-2605
__ ORIGINAL FILING
_
___ AMENDED FILING
ANNUAL REPORT OF PREMIUMS, TAXES AND FEES OF FOREIGN
LIFE AND ACCIDENT & HEALTH INSURANCE COMPANIES
___REFUND DUE
STATE OF DOMICILE
NAIC COMPANY CODE
(5 digit code)
COMPANY NAME
MAILING ADDRESS
CONTACT PERSON
TITLE
TELEPHONE NUMBER
EXT
FAX NUMBER
EMAIL ADDRESS
*The Arkansas tax sections impose 2 1/2% tax on the total direct written premium, less applicable deductions under
ACA 26-57-601 et. seq. Considerations received on annuity contracts are not subject to premium taxes.
Total on Line 1a below must be equal to premium reported on the Annual Statement Schedule T and State Page for Life
Insurance.
Column 1
Column 2
Direct written premium of said Company in Arkansas
Arkansas Tax
State of Domicile Tax
for the calendar year ending December 31, 2011.
on Arkansas Insurer
Tax Rate_________
LIFE, ACCIDENT AND HEALTH PREMIUMS
A.
0.00
0.00
1. a. Life Insurance Premiums
$____________________
$____________________
0.00
0.00
b. Less Army/Air Force Federal Premium
$(___________________)
$(___________________)
0.00
0.00
c. Tax Thereon at 2.5%
$____________________
$____________________
0.00
0.00
2. a. Accident & Health Insurance Premiums
$____________________
$____________________
0.00
0.00
b. Federal Employees Health Benefits Program
$(___________________)
$(___________________)
0.00
0.00
c. Dividends Paid or Credited
$(___________________)
$(___________________)
0.00
0.00
d. Medicare Title XVIII, Tax Exempt
$(___________________)
$(___________________)
0.00
0.00
e. Net Accident & Health Premiums
$____________________
$____________________
0.00
0.00
f. Tax Thereon at 2.5%
$____________________
$____________________
0.00
g. Additional Taxes/Fees from State of Domicile
$XXXXXXXXXXXX
___
$____________________
(Attach Explanation)
0.00
0.00
3. Total Premium Tax Due
$____________________*
$____________________*
[Col. 1,1(c), 2(f)][Col. 2, 1(c), 2(f), (g)]
FEES
B.
0.00
4.
a. Filing Annual Statement
$
50.00 ___ _
$_____________________
b. Certificate of Authority
$
100.00
$_____________________
0.00
c. TOTAL FEES
$
150.00
_ __
$_____________________
0.00
C. GRAND TOTAL OF ALL TAXES & FEES
150.00
0.00
5.
Total Taxes & Fees (A3 + B4c)
$_____________________
$_____________________
Page 1 of 4
REVISED 2011

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