Form Rct-121 - Gross Premiums Tax Report Insurance Companies, Associations Or Exchanges -Commonwealth Of Pennsylvania Page 3

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ATTACH COPY OF PENNSYLVANIA BUSINESS PAGE AND SCHEDULE T OF THE ANNUAL REPORT FILED

WITH THE PENNSYLVANIA INSURANCE DEPARTMENT AND ALL OTHER DOCUMENTATION TO THIS PAGE.

RETALIATORY PROVISIONS UNDER SECTION 212,

ACT OF MAY 17, 1921, P.L. 789, AS AMENDED

If any other state imposes burdens or prohibitions on insurance companies or agents of this State doing business in such other state, which are in addi-

tion to or in excess of, the burdens or prohibitions imposed by this Commonwealth on insurance companies and agents, like burdens and prohibitions

shall be imposed on all insurance companies and agents of such other state doing business in this Commonwealth.

In applying this Section to an insurance company of another state, such company shall not be required to pay any taxes and fees which are greater in

aggregate amount than those which would be imposed by the laws of such other state and any political subdivision thereof upon a like company of this

Commonwealth transacting the same volume and kind of business in such other state.

ANSWER THE FOLLOWING QUESTIONS

(a) How many agents are licensed to represent your Company in Pennsylvania during the tax year?

(b) What are your state fees for licensing agents of similar Pennsylvania insurers?

EXTRAORDINARY MEDICAL BENEFIT PREMIUMS are not subject to tax in accordance with the Act of April 26, 1989, P.L. 6 (Act No. 4).

TAX CREDITS

The following tax credits are available: Pennsylvania Life and Health Insurance Guaranty Association Assessment Credit, Neighborhood Assistance

Credit and Employment Incentive Payments Credit and Job Creation Tax Credit.

Tax credits claimed for Pennsylvania Life and Health Insurance Guaranty Association Assessment and Employment Incentive Payments Credit are not

posted to your account prior to settlement. Therefore, the ledger statement will reflect a debit balance until the credit is approved by the Department of

Revenue. Schedule W must be attached to claim Employment Incentive Payments Credits.

To claim a credit for a Pennsylvania Life and Health Insurance Guaranty Association Assessment, submit a copy of the Assessment Invoice Certificate

of Contribution for the first year a credit is claimed. All pages must be submitted. Include Pennsylvania Page and Schedule T for the year immediately

preceding the year in which the assessment is paid and a schedule of all credits claimed for each type of assessment (i.e. Life Insurance, Accident and

Health Insurance Annuity). Please note that this credit is allowed only for those policies in which the premium rates are guaranteed during the continu-

ance of the respective policies, without a right exercisable by the company to increase said premium rates.

COMPLETING TAX REPORTS

The completed reports must be either typewritten or printed in ink. Authority to reproduce this tax report may be requested and approved, in writing, by

the Department prior to use. To be approved, the report must be identical to the form provided by the Department. Page 1 of the original report must

reflect the name of the corporation and the signature of a corporate official. Taxpayers must complete the mailing instruction box on page 4 to

receive their settlement.

he Revenue Department’s Bureau of Corporation Taxes - Specialty Taxes will answer your specific questions. Call (717) 783-6035 or write to

the bureau at: PA Department of Revenue, Bureau of Corporation Tax, Specialty Taxes, Dept. 280704, Harrisburg, PA 17128-0704. All Retaliatory

Information and/or correspondence should be sent to this address.