Life Elect Pt Form - Statement Of Fees,charges,and Premium Taxes Form - 2011
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4STATE OF NEW HAMPSHIRE DEPARTMENT OF INSURANCE
7/31/2012 8:53
21 SOUTH FRUIT STREET, SUITE 14, CONCORD NH 03301
LIFE ELECT PT FORM
Rev 10/31/2011
STATEMENT OF FEES, CHARGES, AND PREMIUM TAXES
YEAR ENDED DECEMBER 31, 2011
MARCH 15, 2012
NEW HAMPSHIRE ALLOCATION OF PREMIUMS WRITTEN
NH RSA 400-A:31 Taxable Premiums: Gross Direct Premiums/considerations from policies covering property, subjects, or risks located, resident or
to be performed in this state, other than premiums received for reinsurance, including all dividends applied to purchase additional insurance,
membership and policy writing fees, etc., less return premiums/considerations only.
FILING INSTRUCTIONS:
Complete "NH ST PAGE SUM".
Complete the state of domicile basis for premiums written and premium tax.
Enter any business tax credits in the appropriate spaces.
Enter prior year credits applied and cash payments.
Attach the company's schedule T and state page for life & A&H to the return.
Attach a copy of the company's 2010 Business Enterprise Tax return if applicable.
Attach documentation for any "Other Deductions" the company may have taken.
Complete Page one of the premium tax return.
Save electronic copy for the company's files.
Print copy of all pages to file with NH Insurance Department.
METHOD OF PAYMENT
Payment by EFT - EFT should be deposited in the Insurance Department bank account on or before March 15, 2012.
The hardcopy premium tax return should be mailed to NH Insurance Department to arrive not later than March 15, 2012.
Payment by check - Enclose check with a printed copy of complete premium tax return and mail to the address indicated above.
Timely mailing provisions apply. See RSA 400-A:32-a.
See Separate Instructions
The premium tax statement and payment of taxes is due NOT LATER THAN MARCH 15, 2012.
Filing Instr
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