Form 207c - Insurance Premiums Tax Return Captive Insurance Companies - 2012
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1
2Form 207C
Department of Revenue Services
2012
State of Connecticut
Insurance Premiums Tax Return
PO Box 2990
Captive Insurance Companies
Hartford CT 06104-2990
Complete this return in blue or black ink only.
(New 01/13)
Taxpayer Name
Connecticut Tax Registration Number
Federal Employer ID Number (FEIN)
Taxpayer
Address
Number and Street
PO Box
Type
Date Received (DRS Use Only)
or
City or Town
State
ZIP Code
Print
A.
Check if you are filing as a sponsored captive insurance company and enter the number of protected cells covered by this return:
__________
B.
Check if you are filing a consolidated return for two or more companies and enter the number of companies included in this return:
__________
C.
Check if this is an amended return.
Computation of Tax Due on Insurance
1. Gross direct premiums collected or contracted for ...................................................................................
1.
00
2. Other charges (please specify) .................................................................................................................
2.
00
3. Total Premiums: Add Lines 1 and 2 ..........................................................................................................
3.
00
4. Return Premiums ......................................................................................................................................
4.
00
5. Other deductions (please specify) ............................................................................................................
5.
00
6. Total Deductions: Add Lines 4 and 5 ........................................................................................................
6.
00
7. Net Taxable Premiums: Subtract Line 6 from Line 3 ................................................................................
7.
00
8. Tax on Direct Insurance Premiums from Tax Rate Schedule (Direct Rate) ..............................................
8.
00
9. Tax on Reinsurance Premiums from Line 25 ............................................................................................
9.
00
10. Total Tax: Add Lines 8 and 9 .....................................................................................................................
10.
00
11. Enter the amount from Line 10
If Line 10 is more than $200,000, enter $200,000; or
If Line 10 is less than $7,500, enter $7,500; ...............................................................................................
11.
00
1 2. If this is the first year of license in Connecticut, enter $7,500.00..............................................................
12.
00
13. Net tax: Subtract Line 12 from Line 11. If less than zero, enter zero “0” ..................................................
13.
00
14. Payments made with extension request Form 207C EXT ........................................................................
14.
00
15. Subtract Line 14 from Line 13...................................................................................................................
15.
00
16. If late: penalty
(16a) $ _____________ .. plus interest
(16b) $ _____________ See instructions ...
16.
00
17. Balance due with this return .....................................................................................................................
17.
00
Computation of Tax Due on Reinsurance
18. Assumed Reinsurance Premiums collected or contracted for ....................................................................
18.
00
19. Other charges (please specify) ...................................................................................................................
19.
00
20. Total Assumed Reinsurance Premiums: Add Lines 18 and 19 ...................................................................
20.
00
21. Return premiums ........................................................................................................................................
21.
00
22. Other deductions (please specify) ..............................................................................................................
22.
00
23. Total Deductions: Add Lines 21 and 22 ......................................................................................................
23.
00
24. Net Assumed Reinsurance Premiums: Subtract Line 23 from Line 20 .......................................................
24.
00
25. Enter amount due from Tax Rate Schedule (Assumed Rate) .....................................................................
25.
00
Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) and,
to the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or
document to DRS is a fine of not more than $5,000, or imprisonment for not more than five years, or both. The declaration of a paid preparer other than the
taxpayer is based on all information of which the preparer has any knowledge.
Signature of principal officer
Title
Date
Print Name of principal officer
Telephone Number
Sign Here
(
)
Keep a copy
Email Address of principal officer
of this return
for your
Paid Preparer’s Signature
Date
Preparer’s SSN or PTIN
records.
Firm’s Name and Address
FEIN
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