Form 1061 - Annual Premium Tax Statement - Louisiana Department Of Insurance - 2011 Page 3
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6NAIC NUMBER:
COMPANY NAME:
Schedule B: Itemization of Life, Accident & Health Premiums and Tax Calculation (L.R.S. 22§842)
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 D below must be equal to premium reported on the Annual Statement (A.S.) Schedule T
and State Page (Page 24) for Life, Accident & Health, or State Page [Page 19 - lines 13 through 15.8 & (a)] of Property and Casualty, or
Schedule T and Exhibit of Premiums, Enrollment and Utilization (Page 29) for Health/HMOs.
2011 A.S. Reference
PAGE/LINE NUMBER
Direct
P & C
L, A & H
Premiums
ACCIDENT & HEALTH and HMO
1.
Group
19/13
24/24
2.
Federal Employees Health Benefits Program
19/15.8
24/24.1
3.
Credit (Group and Individual)
19/14
24/24.2
4.
Collectively Renewable Policies
19/15.1
24/24.3
5.
Individual Non-Cancelable
19/15.2
24/25.1
6.
Individual Guaranteed Renewable
19/15.3
24/25.2
7.
Individual Non-renewable for stated reasons only
19/15.4
24/25.3
8.
Individual Other (accident only)
19/15.5
24/25.4
9.
Medicare Title XVIII (tax exempt)
19/15.6
24/24.4
10.
Individual All Other
19/15.7
24/25.5
11.
Finance and Service Charges
19/ (a)
(not included above)
LIFE INSURANCE
12.
Ordinary
24/1 Col 1
13.
Credit Life (Group and Individual)
24/1 Col 2
14.
Group
24/1 Col 3
15.
Industrial
24/1 Col 4
SERVICE INSURANCE
16.
Applies to domestic service insurers only
A
TOTAL GROSS PREMIUM
$
PREMIUM EXEMPTED FROM STATE TAX. Cite statute, court decision or other legal basis allowing the exemption. An invalid reason
will be taxed and may be penalized - See Note below. 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
17. Total Exempted Premium
$
B
Total Net Taxable Premium (Line A - Line 17)
$
NOTE: Gross premium may be reduced if the requirements of Danna v. Commissioner of Insurance 228 So. 2d 708 are met for employer-insurer provided
group policies for employees. Also, Federal Employee Health Benefits premium are not taxable if the requirements of 5 U.S.C. §8909 are met.
Medicare Title XVIII premiums are also exempt.
Form 1061 (Revised 10-11)
THIS DOCUMENT IS EXEMPT FROM PUBLIC RECORDS LAW UNDER L.R.S. 44§4
Page 3 of 6
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