Life Elect Pt Form - Statement Of Fees,charges,and Premium Taxes Form - 2011 Page 2
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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
MARCH 15, 2012
Rev 10/31/11
STATEMENT OF FEES, CHARGES, AND PREMIUM TAXES
LIFE, ACCIDENT & HEALTH INSURANCE COMPANIES
YEAR ENDING DECEMBER 31, 2011
COMPANY NAME
STREET, CITY, STATE, ZIP
TYPE OF COMPANY
LIF
FEDERAL TAX ID NUMBER
NAIC GROUP CODE
NAIC COMPANY CODE
STATE OF DOMICILE (2 DIGIT ABBREVIATION)
PLEASE INDICATE METHOD AND AMOUNT OF TAX PAYMENT
CHECK
EFT
IS THIS COMPANY LICENSED FOR VARIABLE ANNUITIES?
Y/N
DID THIS COMPANY AMEND ITS BYLAWS DURING CY 2011?
Y/N
DID THIS COMPANY AMEND ITS ART OF AGREEMENT DURING CY 2011?
Y/N
SWORN STATEMENT (RSA 400-A:31)
State of
County of
Name of Officer
being duly sworn, deposes and says
that he/she is the
, of the
of the
and that the following is a full, true and correct statement of the business done in the State of New Hampshire by said
Company during the year ending December 31, 2011.
Subscribed and sworn to before me this ___________ day of
_______________2012.
Officer
Notary Public
NH RSA 294-E Uniform Electronic Transactions Act
Electronic Signatures
Date, Time and Title
Signature
Return Prepared By
Company Officer
Notary Public
PLEASE INDICATE THE NAME OF THE TAXATION OFFICER WHOM WE SHOULD CONTACT IF THERE ARE QUESTIONS
ABOUT THIS FORM. ALSO INDICATE THE APPROPRIATE ADDRESS FOR CORRESPONDENCE, REFUNDS, ETC.
PREMIUM TAX CONTACT PERSON
ADDRESS (If different from above)
E-MAIL ADDRESS
PHONE NUMBER
EXT
FAX NUMBER
See Separate Instructions
The premium tax statement and payment of taxes is due NOT LATER THAN MARCH 15, 2012.
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