Form 1061 - Annual Premium Tax Statement - Louisiana Department Of Insurance - 2011 Page 2

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NAIC NUMBER:
COMPANY NAME:
Schedule A: Itemization of Fire, Marine, Transportation, Casualty, Surety, and Miscellaneous Premiums (L.R.S. 22§831)
Annual Premium Computation. The annual premium referred to in this part shall be the gross amount of direct premiums, excluding premiums on
annuity contracts, for the preceding year, less return premiums without any deductions for dividends paid or otherwise credited to policyholders, and
§843
without consideration for reinsurance (L.R.S. 22
).
Premiums Written During 2011 - Total on Line 33 below must be equal to premium reported on the Annual Statement (A.S.) Schedule T and State Page
(Page 19) for a Property and Casualty company.
2011 A.S. Reference
(2) Fire (3) Premium for Fire Tax
Page 19 / Line Number
(1) Premium
Allocation Calculation Col 1 x Col 2
Line of Business
100%
1
Fire
1
2
Allied lines
2.1
3
Multiple peril crop
2.2
4
Federal flood
2.3
45%
5
Farm owners multiple peril
3
45%
6
Homeowners multiple peril
4
45%
7
Commercial multiple peril (F&A))
5.1
45%
8
Commercial multiple peril (Liability)
5.2
9
Mortgage guaranty
6
10
Ocean marine
8
11
Inland marine
9
12
Financial guaranty
10
13
Medical professional liability
11
14
Earthquake
12
15
Workers' compensation
16
16
Other liability – occurrence and claims made
17.1, 17.2
17
Excess workers’ compensation
17.3
18
Products liability
18
19
Private passenger auto no-fault (personal injury protection)
19.1
20
Other private passenger auto liability
19.2
21
Commercial auto no-fault (personal injury protection)
19.3
22
Other commercial auto liability
19.4
5%
23
Private passenger auto physical damage (including vehicle fire)
21.1
5%
24
Commercial auto physical damage (including vehicle fire)
21.2
25
Aircraft (all perils)
22
26
Fidelity
23
27
Surety
24
28
Burglary and theft
26
29
Boiler and machinery
27
30
Credit
28
31
Warranty
30
32
Title
N/A
33
Aggregate write-ins for other lines of business
34
34
Finance and service charges (Allocated to Fire & Casualty)
(a)
$
$
35
Add Lines 1 through 34 for Column 1 and Column 3
PREMIUM EXEMPTED FROM STATE TAX. Cite statute, court decision or other legal basis allowing the exemption. An invalid reason will
36
be taxed and may be penalized. Federally Reinsured Crop and Bail Bond premiums are not taxable. In the space provided below, identify
the line number listed above, the reason allowing the exemption, and the exempted premium amount.
Line # Reason for exempting premium:
Premium Amount
A
Total Exempted Premium
$
B
Net Taxable Premium (Line 35, Column 1 – Line A)
$
C
Fire Marshal Tax – Tax rate 0.0125 x Line 35, Column 3 - L.R.S. 22§835
$
D
Fire Department Tax - Tax rate 0.0200 x Line 35, Column 3 - L.R.S. 22§345
$
E
Firemen Training Program Tax - Tax rate 0.0025 x Line 35, Column 3 - L.R.S. 22§837
$
Form 1061 (Revised 10-11)
THIS DOCUMENT IS EXEMPT FROM PUBLIC RECORDS LAW UNDER L.R.S. 44§4
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