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Unlicensed Companies' Premium Tax Report Form - State Of New Hampshire Department Of Insurance - 2013

STATE of NEW HAMPSHIRE

DEPARTMENT OF INSURANCE

UNLICENSED COMPANIES’ PREMIUM TAX REPORT

YEAR ENDED DECEMBER 31, 2012

Property & Casualty Companies Due Date: March 1, 2013

Name of Company _______________________________________________________________

Address of Company _____________________________________________________________

Federal Tax Identification Number _________________________________________________

NAIC Group Code___________ NAIC Company Code__________ Domestic State __________

1. Schedule T, Direct Premium Written, Line 30

__________________

2. Schedule T, Finance and Service Charges, Line 30

__________________

3. Total (Line 1 + Line 2)

__________________

4. Premiums from NH “Move-Ins” (Attach Schedule)

__________________

5. Taxable amount at 4% Tax (Line 3 less Line 4)

__________________

6. Tax Due at 4% Tax Rate (Line 5 x 4%)

___________________

7. Tax Due at 2% Tax Rate (Line 4 x 2%)

___________________

8. Total Tax Due (Line 6 + Line 7)

___________________

The undersigned certifies that this report is true and correct according to the best of his information,

knowledge, and belief.

_______________________________________________________

___________

PREPARER

TITLE

DATE

CONTACT INFORMATION:

ADDRESS _____________________________________________

_____________________________________________

Unlicensed companies are not required to pay quarterly estimated tax payments.

Amounts taken as tax credit for NH “Move-Ins” should be supported by documentation showing location of

policyholder when policy was obtained and current location of policyholder.

RSA 406-B:11,II

“If the tax prescribed by this subsection is not paid within the time stated, the tax shall be increased by a penalty of 25

percent and by the amount of an additional penalty computed at the rate of none percent per month or any part thereof

from the date such payment was due to the date paid.”

STATE of NEW HAMPSHIRE

Unlicensed Companies' Premium Tax Report Form - State Of New Hampshire Department Of Insurance - 2013