Form Ins-7 - Nonadmitted Premiums Tax Annual Reconciliation / Return - 2011
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1
2FORM INS-7
MAINE REVENUE SERVICES
99
NONADMITTED PREMIUMS TAX
2011
(SELF PROCURED & SURPLUS LINES)
*1132000*
ANNUAL RECONCILIATION / RETURN
Maine Surplus Lines Account Number
Period Covered
Due Date
January 1 - December 31, 2011
March 15, 2012
PRODUCER’S NAME, ADDRESS AND NAME OF PRODUCER’S COMPANY OR EMPLOYER:
CHECK ALL THAT APPLY:
Initial return
Producer’s or Self Procured Person’s Name
Amended return
Street Address and/or Post Offi ce Box
Made estimated payments
during the year
City
State
ZIP Code
Change of name/address
Name of Producer’s Company or Employer
Tax Computation
Check this box if reporting self procured premiums on line 1.
.00
,
,
$
1.
Nonadmitted Gross Direct Insurance Premiums ........................................................... 1.
2.
DEDUCTIONS
,
,
.00
$
2a. Return premiums .............................................................................................. 2a.
,
,
.00
$
2b. Dividends paid, credited or allowed on direct premiums ................................. 2b.
,
,
.00
$
3.
Total Deductions (line 2a plus line 2b) ............................................................................ 3.
,
,
$
.00
4.
Amount Taxable (line 1 minus line 3) ............................................................................ 4.
,
,
.00
$
5.
Premiums Tax (line 4 x 0.03) ......................................................................................... 5.
,
,
.00
$
6.
Estimated Payments ..................................................................................................... 6.
,
,
.00
$
7.
Balance Due (If line 5 is greater than line 6, line 5 minus line 6) .................................. 7.
,
,
.00
$
8.
Overpayment (If line 6 is greater than line 5, line 6 minus line 5) ................................. 8.
,
,
.00
$
9a. Portion of overpayment on line 8 to be APPLIED to next year’s ESTIMATED tax ....... 9a.
,
,
.00
$
9b. Portion of overpayment on line 8 to be REFUNDED (line 8 minus line 9a) ................. 9b.
2012 Quarterly Estimated Tax
The 2012 quarterly tax payments may be on an estimated basis, as long as the April 30 and June 25 installments each equal at least 35% of the total tax paid for 2012
or 35% of the total tax due for 2011. The October installment must equal 15% of the total tax paid for 2011 or 15% of the total tax due for 2012. See Form INS-6 for
details. (36 MRSA § 2521-A).
AFFIDAVIT AND SIGNATURE
This return is made in compliance with the provisions of 36 MRSA § 2521-A. The amount of all nonadmitted insurance premiums on insurance subject to Maine
tax for the above period has been reported. Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements,
and to the best of my knowledge and belief, they are true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which
preparer has any knowledge.
Date: _________________________ Signature: ___________________________________________ Phone
#:
___________________________
Must be signed by the Self Procured Person or Producer with Nonadmitted Insurance Authority.
Preparer’s
Date: _________________________ Signature: ___________________________________________ ID Number: _________________________
If enclosing a check, make check payable to:
If not enclosing a check,
Treasurer, State of Maine
MAIL RETURN TO:
and MAIL WITH RETURN TO:
MAINE REVENUE SERVICES
MAINE REVENUE SERVICES
P.O. BOX 1064
P.O. BOX 1065
Rev. 11/11
AUGUSTA, ME 04332-1064
AUGUSTA, ME 04332-1065
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