Med Elect Pt Form - Statement Of Fees,charges,and Premium Taxes Form

Med Elect Pt Form - Statement Of Fees,charges,and Premium Taxes Form - 2011

STATE OF NEW HAMPSHIRE DEPARTMENT OF INSURANCE

7/31/2012 8:59

21 SOUTH FRUIT STREET, SUITE 14, CONCORD NH 03301

MED 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:

Produce an Underwriting and Investment Exhibit for calendar year 2011.

Produce a Schedule T for calendar year 2011.

Using schedule T, complete page three for both the NH Basis and the state of domicile basis.

Enter any business tax credits in the appropriate spaces.

Enter prior year credits applied and cash payments.

Complete pages two and page three of the premium tax return.

Attach the underwriting and investment exhibit and the schedule T.

Attach a copy of the company's 2010 Business Enterprise Tax return if applicable.

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 completed premium tax form 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

Med Elect Pt Form - Statement Of Fees,charges,and Premium Taxes Form - 2011