Form Ins-5 - Fire Investigation And Prevention Tax Annual Reconciliation/return - 2011
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1
2FORM INS-5
MAINE REVENUE SERVICES
99
2011
FIRE INVESTIGATION AND PREVENTION TAX
ANNUAL RECONCILIATION / RETURN
*1131100*
MRS Fire Tax Account Number
NAIC ID Number
Period Covered
Due Date
-
March 15, 2012
January 1 - December 31, 2011
Name/Address:
CHECK ALL THAT APPLY:
Business Name (Line 1)
Initial return
Amended return
Business Name (Line 2)
Final return
Street Address and/or Post Offi ce Box
Enter closing date: ___ /___ /_____
MM DD YYYY
Change of name/address
City
State
ZIP Code
COMPUTATION OF TAX ON FIRE PREMIUMS
1.
Amount of premiums allocated to fi re (See instructions)
A
B
C
D
E
F
Line of Business
Gross Premiums
Dividends Paid
Total Net
% of Premiums
Amount of Premiums
(Less Return Premiums
or Credited on
Taxable
Allocated to Fire
Allocated to Fire
and Premiums on
Direct Business
Premiums
(column D x column E)
Policies not Taken)
,
,
$
.00
1a. Fire ........................ $ _________________ $ ________________ $ _________________
100.00%
,
,
$
.00
1b. Inland Marine ........ $ _________________ $ ________________ $ _________________
26.89%
1c. Aircraft Physical
,
,
$
.00
Damage ................. $ _________________ $ ________________ $ _________________
Actual*
Auto Physical Damage:
$
,
,
1d. Private ................... $ _________________ $ ________________ $ _________________
1.24%
.00
$
,
,
1e. Commercial ........... $ _________________ $ ________________ $ _________________
4.66%
.00
Fire, Theft and Miscellaneous:
.00
,
,
$
1f. Farmowners .......... $ _________________ $ ________________ $ _________________
43.67%
Multiple Peril
$
.00
,
1g. Homeowners ......... $ _________________ $ ________________ $ _________________
47.13%
,
Multiple Peril
,
,
.00
$
1h. Commercial ........... $ _________________ $ ________________ $ _________________
50.13%
Multiple Peril (non-liability)
.00
,
,
$
1i. All Other Fire ......... $ _________________ $ ________________ $ _________________
100.00%
Related
$
.00
,
,
2. Total amount of premiums allocated to fi re (Add lines 1a through 1i) ....................................................2.
$
.00
,
,
3. Tax liability (line 2 multiplied by 1.4% (0. 014)) .....................................................................................3.
$
.00
,
,
4. Estimated payments .............................................................................................................................4.
$
.00
,
,
5. Balance due (If line 3 is greater than line 4, line 3 minus line 4) ..........................................................5.
$
.00
,
,
6. Overpayment to be refunded (If line 4 is greater than line 3, line 4 minus line 3) ..................................6.
* Line 1c only: Enter in column F the premiums actually received on fi re risks located in Maine.
Rev. 11/11
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