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Form Rct-122 - Gross Premiums Tax Report For Premiums Paid To Unauthorized Foreign Insurance Companies, Associations, Exchanges, Etc. Page 2

RCT-122

Page 2

1220011201

Beginning

Policy

Type of

Amount of

Name of Insurance Company

Location of Risk

Date of Policy

Gross Premiums

Number

Insurance

and Term

(Attach additional schedules if necessary)

Total Gross Premiums on Life Insurance and Annuities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

Less: Total of Net Premiums returned on cancelled policies of Life Insurance and Annuities . . . . . . . . . . . . . . . . . . . . $

Gross Premiums Taxable on Life Insurance and Annuities (Line 1 less Line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

Total Gross Premiums on all other types of Insurance reported above . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

Less: Total of Net Premiums returned on cancelled policies of all other types of Insurance reported above

. . . . . . . . . $

Gross Premiums Taxable on all other types of Insurance reported above (Line 4 less Line 5) . . . . . . . . . . . . . . . . . . . $

Tax at Rate of 2 percent of Gross Premiums Taxable on Life Insurance and Annuities (Line 3 x 0.02) . . . . . . . . . . . . . $

Tax at Rate of 3 percent of Gross Premiums Taxable on all other types of Insurance reported above (Line 6 x 0.03) . . . $

➧

Total Tax (Line 7 plus Line 8; enter this amount on Page 1, Column A in whole dollars only) . . . . . . . . . . . . . . . . . . . . $

1220011201

Form Rct-122 - Gross Premiums Tax Report For Premiums Paid To Unauthorized Foreign Insurance Companies, Associations, Exchanges, Etc. Page 2