Form Ins-4 - Insurance Premium Tax Return - 2004
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4FORM INS-4
MAINE REVENUE SERVICES
00
INSURANCE PREMIUM TAX RETURN
*0430000*
MRS Insurance Account Number
NAIC Company Code
Period Covered
Due Date
January 1- December 31, 2004
March 15, 2005
Name/Address:
CHECK APPLICABLE SPACES:
Initial return
Business Name (Line 1)
Amended return
Final return
Business Name (Line 2)
Risk Retention Group
Street Address and/or Post Office Box
Domiciled in Maine
Change of name/address
City
State
Zip Code
$
,
,
,
.00
Enter total assets reported on annual statement: ..................................................................
Part A – Maine Tax Computation
Premiums:
,
,
.00
1a. Accident and Health Premiums ............................................................................................. 1a.
,
,
.00
1b. Life Premiums ........................................................................................................................ 1b.
,
,
.00
1c. Property and Casualty Premiums (other than workers’ compensation premiums) .............. 1c.
,
,
.00
1d. Workers’ compensation premiums ........................................................................................ 1d.
,
,
.00
1e. Title insurance premiums ....................................................................................................... 1e.
,
,
.00
1f. Total Gross Direct Premiums (Add lines 1a through 1e) .................................................... 1f.
,
,
.00
1g. Annuity Considerations received this tax year (See Instructions) ...................................... 1g.
,
,
.00
1h. Annuity Considerations received prior to January 1, 1999 (See Instructions) ................... 1h.
,
,
.00
1i. Total Annuity Considerations (Add lines 1g and 1h) ........................................................... 1i.
,
,
.00
1j. Total Premiums (Add lines 1f and 1i) ................................................................................... 1j.
Deductions:
,
,
.00
2. Direct return premiums or deposits thereon (Schedule 1, line 1, column H) ......................... 2.
,
,
.00
3. Dividends paid, credited or allowed on direct premiums (Schedule 1, line 2, column H) ...... 3.
,
,
.00
4. Premiums exempt under qualified pension plans (Schedule 1, line 3, column H) ................. 4.
,
,
.00
5. Other Deductions (Schedule 1, line 4, column H) ................................................................... 5.
,
,
.00
6. Total Deductions (Add lines 2, 3, 4 and 5. Total should equal Schedule 1, line 5, column H) 6.
Tax:
7. Total net taxable premiums
,
,
.00
( Line 1j minus line 6) ...................... 7.
8. Net premiums on qualified group
disability policies written by large
,
,
,
,
.00
.00
domestic insurer taxable at 2.55% 8a.
X 2.55% 8b.
9. Net premiums on qualified group
disability & certified long-term
,
,
,
,
.00
.00
care policies taxable at 1% ........... 9a.
X 1.00% 9b.
,
,
,
,
.00
.00
10. Net premiums taxable at 2% ...... 10a.
X 2.00% 10b.
,
,
.00
11. Total Tax on Maine basis (Total of lines 8b, 9b and 10b. Can not be less than zero.) ...... 11.
INS-4 Rev. 11/04
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