Form 314 - Annual Premium Tax Statement - 2013 Page 4
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5Name of Insurer
EXHIBIT NO.:
4
INFORMATION:
Premium Tax Statement for the Year Ended December 31, 2013
APPLICABLE TO:
ALL INSURERS
Round All Amounts to Nearest Dollar
DETAIL OF CREDITS AND PAYMENTS
PLEASE PROVIDE COMPLETE SUPPORT FOR ANY CREDIT TAKEN
CREDITS:
Hawaii Life & Disability Insurance Guaranty
Association Assessments . . . . . . . . . . . .
$ _NONE__________________
Tax Credit to Facilitate Regulatory Oversight
(If qualified---see HRS §431:7-207) . . . . . .
$ ________________________
___________________________________ . . .
$ ________________________
___________________________________ . . .
$ ________________________
___________________________________ . . .
$ ________________________
1.
TOTAL CREDITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________________________
(to line 5, page 1)
PAYMENTS:
MONTHLY Premium Tax Payments for 2013:
MONTH Ended JANUARY 31, 2013
$
MONTH Ended FEBRUARY 28, 2013
$
MONTH Ended MARCH 31, 2013
$
MONTH Ended APRIL 30, 2013
$
MONTH Ended MAY 31, 2013
$
MONTH Ended JUNE 30, 2013
$
MONTH Ended JULY 31, 2013
$
MONTH Ended AUGUST 31, 2013
$
MONTH Ended SEPTEMBER 30, 2013
$
MONTH Ended OCTOBER 31, 2013
$
MONTH Ended NOVEMBER 30, 2013
$
MONTH Ended DECEMBER 31, 2013
$
AMENDED Month Ended
$
AMENDED Month Ended
$
AMENDED Month Ended
$
AMENDED Month Ended
$
$__________________________
TOTAL MONTHLY Premium Tax Payments for 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2012 PRIOR YEAR Premium Tax Overpayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$__________________________
If AMENDED filing, amount paid with ORIGINAL filing . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$__________________________
2.
TOTAL PAYMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________________________
(to line 7, page 1)
COMPLETE EVERY ITEM OF EACH EXHIBIT. Enter “NONE” where no entries are to be made.
REMINDERS BEFORE MAILING:
1.
Tax Statement signed AND dated by a duly authorized officer of the Company?
2.
Total payments include the last monthly tax payment? [December 31, 2013 - due January 20, 2014]
3.
Carry forward the correct prior year overpayment? If the Tax Statement was amended, carry
forward the amended prior year overpayment amount.
4.
ROUND TO NEAREST DOLLAR ALL AMOUNTS REPORTED ON THE TAX STATEMENT.
5.
Premium tax payments should be made payable to: DEPARTMENT OF COMMERCE AND
CONSUMER AFFAIRS (“DCCA”), STATE OF HAWAII.
6.
Pages 1 through 4 of the Tax Statement are required. File page 5 (Supplemental Schedule A) ONLY
if applicable --- if Schedule A is NONE, do not file page 5.
7.
Form must be on LEGAL SIZE PAPER --- LETTER SIZE WILL NOT BE ACCEPTED.
8.
Correct insurer address? ALL TAX RELATED CORRESPONDENCE from the Hawaii Insurance
Division will be sent to the address listed on page 1 of the Tax Statement.
Page 4
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