Form 74a100 - Insurance Premiums Tax Return - 2002 Page 3
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474A100 (12-02)
Page 3
SECTION II. OTHER THAN LIFE INSURANCE TAX (Kentucky Revised Statutes 136.340, 136.350, 136.370 and 136.390)
A.
Gross amount of premiums received (Include policy and membership fees. Do not include premiums for
federally insured crop and federally insured flood insurance (direct written premium and write-your-own
policies only).) .......................................................................................................................................................................
B.
Other amounts received for insurance or incidental services related to insurance ....................................................................
C.
Gross amount received from reinsurance assumed on Kentucky risks from unauthorized companies .....................................
(Attach itemized account of all reinsurance assumed on Kentucky risks.)
D.
Total lines A, B and C ............................................................................................................................................................
E.
1.
Returned premiums
(Exclude amounts applicable to workers’ compensation.) ....................................................
2.
Dividends paid or credited by mutual companies to policyholders
(Exclude amounts applicable to workers’ compensation.) ....................................................
3.
Workers’ compensation insurance premiums included on line D .........................................
F.
Total lines E-1, E-2, and E-3 ..................................................................................................................................................
G.
Total taxable premiums (subtract line F from line D) .............................................................................................................
H.
Other than life insurance tax liability (2% of line G) ..............................................................................................................
I.
Life and Health Guaranty Fund Assessment credit .................................................................................................................
J.
Net other than life insurance tax liability (subtract line I from line H; if line I exceeds line H, enter zero) ..............................
First Installment
Second Installment
K.
1.
Other than life insurance tax paid by declaration ............................
2.
Adjustments (attach adjustments) ........................................................................................
L.
Total lines K-1 and K-2 ..........................................................................................................................................................
M.
Other than life insurance tax due (subtract line L from line J and enter here and on line B, page 1) ........................................
$
SECTION III. FIRE INSURANCE TAX (Kentucky Revised Statutes 136.350, 136.360, 136.370 and 136.390)
Enter Amounts
Enter Amount
A. Complete the following schedule:
Enter Gross
Refunded on
Allocated to Fire
Subtract
Percentage
Policies not Taken
(Multiply amount
Amount Received
or Cancelled and
Column 2 from
Allocated
in Column 3
Regardless of
Dividends Paid
by percentage
Column 1
to Fire
Line of Business
Designation
or Credited to
in Column 4)
Policyholders
(3)
(4)
(1)
(2)
(5)
1.
Fire ......................................................................
100
2.
Inland marine .........................................................
15
3.
Aircraft physical damage .......................................
20
4.
Auto physical damage:
a.
Comprehensive ..............................................
37.5
b.
Fire and theft ..................................................
74.8
c.
Fire, theft and miscellaneous ..........................
67.8
5.
Comprehensive dwelling ........................................
33.3
6.
Home owners’ policies A, B, C and tenants ............
33.3
7.
Manufacturers’ output policy .................................
33.3
8.
Multiple peril .........................................................
50
9.
Other (specify) .......................................................
B.
Amount allocated to fire (add lines 1 through 9) ...............................................................................................................................
C.
Adjustments (negative amounts and other documented adjustments) ................................................................................................
D.
Total lines B and C ...........................................................................................................................................................................
E.
Fire insurance tax (multiply line D by .0075 and enter here and on line C, page 1) ...........................................................................
$
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