Form Rct-121-A - Gross Premium Tax - 2011 Page 2
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21211011201
RCT-121-A (I)
Page 2
ATTACH COPY OF PENNSYLVANIA BUSINESS PAGE AND SCHEDULE T OF THE ANNUAL REPORT FILED WITH THE PENNSYLVANIA INSURANCE
DEPARTMENT.
Fire, Casualty and Title Insurers (Do not include Ocean Marine Premiums.)
1.
Gross Direct Premiums Received Less Cancellations and Premiums Returned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
2.
Less: Extraordinary Medical Benefit Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.
Less: Dividends to Policyholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.
Less: Other Deductions (Attach schedule.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.
Premiums Taxable (Line 1 minus Lines 2, 3 and 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Life Insurers
6.
Gross Life Premiums (Direct Writing Basis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
7.
Less: Dividends to Policyholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8.
Less: Other Deductions (Attach schedule.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9.
Life Premiums Taxable (Line 6 minus Lines 7 and 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accident and Health Insurers
10. Gross Direct Accident and Health Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
11. Less: Dividends to Policyholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12. Less: Other Deductions (Attach schedule.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13. Accident and Health Premiums Taxable (Line 10 minus Lines 11 and 12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14. Total Taxable Premiums (Add Lines 5, 9 and 13) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15. Tax (Line 14 times 0.02) Domestic Life, Fire or Casualty - 2 percent; Enter this amount on Page 1, Column A . . . . . . . . . . . . . . . . .
(whole dollars only)
1211011201
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Parent category: Financial