Form 176-I - Preferred Provider Gross Revenue Excise Return - 2004

2004

Form 176-I

Massachusetts

Preferred Provider Gross Revenue

Department of

Excise Return

Revenue

Taxable under the provisions of MGL Chapter 63, section 23 as provided by Chapter 176-I, section 11. For the taxable year ending December 31, 2004.

Name of corporation

Federal Identification number

Address of principal office

City/Town

State

Zip

Approval date from Division of Insurance

Mailing address

City/Town

State

Zip

Organized under the laws of

Name of treasurer

Type of organization:

Accident and health insurer

Nonprofit hospital

HMO

Optometric service corporation

Nonprofit medical service corporation

Dental service corporation

Other ________________________

Has the federal government changed your taxable income for any prior year which has not yet been reported to Massachusetts?

Yes

No.

Computation of Excise

Income

Use whole dollar method

❿ 1

11 Gross premiums received for coverage of covered persons residing in Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(premiums for Medicare Supplemental Coverage are excludable)

12 Premiums returned or credited to policyholders as dividends (unabsorbed premium deposits) on direct business . . . . . . . . ❿ 2

Excise

13 Taxable amount. Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

14 Tax at 2.28%. Multiply line 3 by .0228 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 4

15 Credit recapture (attach Schedule H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 5

16 Tax due before credits. Add lines 4 and 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 6

17 Full Employment Credit (attach Schedule FEC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 7

18 Low-Income Housing Credit (attach documentation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 8

19 Excise due before voluntary contribution. Subtract the total of lines 7 and 8 from line 6. Not less than “0” . . . . . . . . . . . . . . . . . 9

10 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 10

11 Excise due plus voluntary contribution. Add lines 9 and 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 11

Payments

12 2003 overpayment applied to 2004 estimated tax. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 12

13 2004 Massachusetts estimated tax payments. Do not include amount from line 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 13

14 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿14

15 Total payments. Add lines 12 through 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Refund or Balance Due

16 Amount overpaid. Subtract line 11 from line 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

17 Amount overpaid to be credited to 2005 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 17

18 Amount overpaid to be refunded. Subtract line 17 from line 16. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 18

19 Balance due. Subtract line 15 from line 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

20 M-2220 penalty ❿ $ _____________ ; Other penalties ❿ $______________ ; . . . . . . . . . . . . . . . . . . . . . . . . Total penalty 20

21 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 21

22 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 22

Under the penalties of perjury, I declare that to the best of my knowledge and belief this return and enclosurers are true, correct and complete.

Signature of appropriate corporate officer

Social Security number

Telephone number

Date

Individual or firm signature of preparer

Employer Identification number

Address

Date

❿

If you are signing as an authorized delegate of the appropriate corporate officer, check here

and attach Massachusetts Form M-2848, Power of

Attorney. The Privacy Act Notice is available upon request. This return, together with payment in full, is due on or before March 15, 2005. Mail to: Mass-

achusetts Department of Revenue, PO Box 7052, Boston, MA 02204. Make remittance payable to: Commonwealth of Massachusetts.