Form Rct-121 - Gross Premiums Tax Report Insurance Companies, Associations Or Exchanges -Commonwealth Of Pennsylvania Page 2
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RETALIATORY INFORMATION SCHEDULE
Complete information below necessary to permit a calculation of the aggregate amount of regularly recurring taxes, assessments, licenses and fees
which would be imposed on a similar Pennsylvania insurer writing the same kind and amount of insurance in your state of domicile.
For each tax based on premiums, show the percentage rate and all items used in the determination of the amount to which the rate is applicable, includ-
ing gross premiums, return premiums and dividends to policyholders. Include reinsurance assumed from unlicensed insurers if your state of domicile
imposes a base tax on net direct premiums plus reinsurance assumed from unlicensed insurers.
You must furnish sufficient detail in the following information schedule and supplementary attachments, if any, to enable the PA Department of Revenue
to calculate the amount of retaliatory payable. If your state of incorporation imposes a franchise or income tax, submit a copy of the tax return as filed
in your state and a copy of the tax return substituting Pennsylvania totals for your state totals. If a state extension of time is obtained, submit this infor-
mation within thirty (30) days after filing in your state.
PAYMENT FOR RENEWAL OF CERTIFICATE OF AUTHORITY AND FILING FEES MUST BE REMITTED ON A SEPARATE CHECK PAYABLE TO THE
PENNSYLVANIA INSURANCE DEPARTMENT, COMPANIES DIVISION, 13TH FLOOR STRAWBERRY SQUARE, HARRISBURG, PA 17120. DO NOT
REMIT UNTIL BILLED BY THE INSURANCE DEPARTMENT
IN DECEMBER OF 1991, A BULLETIN WAS ISSUED BY THE PA INSURANCE DEPARTMENT NOTIFYING AFFECTED COMPANIES TO REPORT AND
PAY RETALIATORY LICENSES AND FEES DIRECTLY TO THE PA DEPARTMENT OF REVENUE. THEREFORE, BEGINNING WITH THE 1992 TAX
YEAR, RETALIATORY LICENSES AND FEES MUST BE REPORTED ON THIS SCHEDULE AND PAID TO THE PA DEPARTMENT OF REVENUE.
SCHEDULE OF TAXES, ASSESSMENTS, LICENSES AND FEES
PENNSYLVANIA
STATE OF INCORPORATION
Premium Taxes:
Fire, Casualty and Title Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
$
Ocean Marine Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Annuities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accident and Health Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reinsurance Assumed from Unauthorized Companies . . . . . . . . . . . .
Other Taxes (Fire Marshal, Franchise, Income, etc.)
Worker’s Compensation Assessments:
Other Assessments:
Licenses and Fees (Annual Basis):
Totals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
$
Retaliatory Payable to the PA Department of Revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
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