Life Elect Pt Form - Statement Of Fees,charges,and Premium Taxes Form - 2011 Page 3
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2
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40
0
0
YEAR ENDING DECEMBER 31, 2011
PREMIUM TAX: LIFE COMPANIES - RETALIATORY PROVISION NH RSA 400-A:35
(1)
(2)
(3)
(4)
STATE OF
LARGER OF
LICENSING, FILING AND DOCUMENT FEES ONLY
NH BASIS
DOM BASIS
COL 2 OR 3
1. Certificate of Authority Renewal
100
100.00
2. Variable Annuity License Fee (Only if Licensed for Variable Products)
100
0.00
3. Total License Fees
XXXXX
XXXXX
100.00
4. Annual Filing Fees
a) Annual Statement
100
100.00
b) Certificate of Compliance
5
5.00
c) Certificate of Deposit
5
5.00
d) Certificate of Valuation
5
5.00
5. Other Fees which might be applicable
a) By-Laws (ONLY if amending)
25
0.00
b) Articles of Incorporation (ONLY if amending)
35
0.00
c) Other Retaliatory Fees (itemize)
XXXXX
0.00
Publication Fee
XXXXX
0.00
Annual Statement Audit Fee
XXXXX
0.00
Other Fees - Attach Schedule
XXXXX
0.00
6. TOTAL FILING FEES
XXXXX
XXXXX
115.00
STATE OF
OTHER TAXES, FEES, AND ASSESSMENTS
NH BASIS
DOM BASIS
TAX
Calculation of taxes based upon laws governing state of domicile (Include % rate and basis if applicable).
XXXXX
XXXXX
7. FRANCHISE TAX
(If subject to a minimum, include this minimum amount $__________)
XXXXX
0.00
8. CORPORATE TAX
XXXXX
0.00
9. DISTRICT/MUNICIPALITY
XXXXX
0.00
10. COUNTY/CITY/CANADIAN PROVINCE TAX
XXXXX
0.00
11. INVESTMENT TAX
XXXXX
0.00
12. FINANCIAL REGULATION FEE
XXXXX
0.00
13. STATE RATING BUREAU
XXXXX
0.00
14. ATTORNEY GENERAL
XXXXX
0.00
15. FRAUD
XXXXX
0.00
16. ACTUARY
XXXXX
0.00
17. RATE HEARING
XXXXX
0.00
18. INSURANCE DEPARTMENT MAINTENANCE
0.00
19.
XXXXX
0.00
20.
XXXXX
0.00
21.
XXXXX
0.00
22.
XXXXX
0.00
23.
XXXXX
0.00
24.
XXXXX
0.00
25
XXXXX
0.00
26.
XXXXX
0.00
27
XXXXX
0.00
28.
XXXXX
0.00
29. OTHER - ATTACH SCHEDULE
XXXXX
0.00
30. TOTAL OTHER TAXES, FEES, AND ASSESSMENTS
XXXXX
XXXXX
0.00
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