Form Ins-5 - Fire Investigation And Prevention Tax Annual Reconciliation/return - 2011 Page 2

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2011 FORM INS-5, Page 2
99
-
*1131101*
MRS Fire Tax Account Number:
AFFIDAVIT AND SIGNATURE
This return is made in compliance with the provisions of 25 MRSA § 2399. The amount of all GROSS DIRECT PREMIUMS or assessments for fi re
risks written by this insurer on risks located in, or received from risks resident of, the State of Maine during the year ending December 31, 2011 has
been reported. Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best
of my knowledge and belief, they are true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which
preparer has any knowledge.
Date: _________________________ Signature: ___________________________________________ Telephone #: ________________________
Must be signed by the President, Treasurer, Secretary, Chief Accounting Offi cer or Attorney-in-fact of a reciprocal insurer.
Preparer’s
Date: _________________________ Signature: ___________________________________________ ID Number: _________________________
INSTRUCTIONS
Premium amounts to be reported: A premium is an amount paid or
associated with risks located in Maine.
payable for an insurance policy, including all fees, such as membership,
c.
Divide a by b; this is the ratio to be used in column E for this
policy, survey, inspection, service and fi nance fees, that are assessed by
particular product line.
and paid to an insurance company in consideration for an insurance policy.
d.
A separate calculation must be made for each product line.
The instructions below provide guidance to assist in the preparation of
e.
In the case of affi liated insurance companies, a separate
this return. However, accurate and full reporting of premium amounts,
calculation must be made for each insurer.
including any applicable fees, is the responsibility of each taxpayer.
3.
Attach a computation to your return identifying loss due to fi re
Note: The fi re investigation and prevention tax applies in addition to
and total loss by year for each of the fi ve years used to calculate
the insurance premiums tax.
the fi ve-year average.
Line 1. Amount of Premiums Allocated to Fire.
Calculate the total
Column F. Multiply the column D amount by the column E percentage
amount of premiums allocated to fi re insurance for each line of business
and enter the result.
identifi ed in column A.
Line 2. Total Premium.
Add column F amounts for each line of business
Column B. Enter the gross direct premiums written, less return
(line 1a. through line 1i.) and enter the sum on this line (Total amount of
premiums and premiums on policies not taken. Generally, gross
premiums allocated to fi re).
direct premiums are reported on the Maine State Page of the NAIC
Annual Statement, column 1 and related fi nance and service charges
Line 3. Tax Liability.
Every fi re insurance company or association that
does business or collects premiums or assessments in Maine is required
are reported on Schedule T, column 8 (Finance and Service Charges
not Included in Premiums).
by statute to pay 1.4% of the net taxable premiums for fi re risks written
in Maine.
Column C. Enter dividends paid or credited to policyholders on direct
premiums. Amounts entered must agree with column 3 of the Maine
Line 4. Estimated Payments.
Enter the total amount of monthly
portion of your NAIC annual statement.
estimated payments already made in 2011.
Column D. Subtract the column C amount from the column B amount
Line 5. Balance Due.
Payment must be submitted with this return.
and enter the result.
Late payments are subject to interest and penalties.
Column E. The percentages listed represent the ratio of fi re losses
to total losses based on historical data. An insurer wanting to deviate
Note: Certain taxpayers with large annual tax liabilities are required
from these percentages must clearly establish alternate ratios based
to remit tax payments electronically. See Maine Rule 102 on the MRS
on its own fi re loss experience. The following procedures must be
web site (select Laws & Rules) for details.
used to establish alternate fi re ratios:
For calendar year 2012, the interest rate is 7%, compounded monthly.
1.
The alternate ratios must be based on the prior fi ve-year average
The penalty for failure to fi le a return is the greater of $25 or 10% of
fi re losses.
the tax due. If the return is not fi led within 60 days after the receipt of
2.
Complete the following steps to calculate the ratio for each
a demand notice to fi le, the penalty is the greater of $25 or 25% of the
product line listed in column A:
tax due. The penalty for failure to pay a tax liability on time is 1%, up to
a.
Calculate the fi ve-year average of loss due to fi re from claims
a maximum of 25%, of the outstanding liability.
associated with risks located in Maine.
Line 6. Overpayment.
All overpayments will be refunded.
b.
Calculate the five-year average of loss from all claims
If not enclosing a check,
If enclosing a check, make check payable to:
MAIL RETURN TO:
Treasurer, State of Maine
and MAIL WITH RETURN TO:
MAINE REVENUE SERVICES
MAINE REVENUE SERVICES
P.O. BOX 1064
P.O. BOX 1065
AUGUSTA, ME 04332-1064
AUGUSTA, ME 04332-1065

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