Form 176-I - Preferred Provider Gross Revenue Excise Return - 2000

2000

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, 2000.

Name of corporation

Federal Identification number

Address of principal office

Department of Revenue use only

Mailing address

Organized under the laws of

Name of treasurer

Approval date from Division of Insurance

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.

If “Yes,” report such change on Form CA-6, Application for Abatement/Amended Return, within three months of the final federal determination.

Computation of Excise

Income

Use whole dollar method

❿ 1

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

$

(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 Economic Opportunity Area Credit (Schedule EOA, line 9). If this credit was claimed on Form 63-20-23,

DL-1 or DL-2, do not claim it on this form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 5

16 Full Employment Credit (Schedule FEC). If this credit was claimed on Form 63-20-23, DL-1 or DL-2, do not

claim it on this form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 6

17 Excise due before voluntary contribution. Subtract the total of line 5 and line 6 from line 4. Not less than “0” . . . . . . . . . . . . . . 7

18 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 8

19 Excise due plus voluntary contribution. Add line 7 and line 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 9

Payment

10 1999 overpayment applied to 2000 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 10

$

11 2000 Massachusetts estimated tax payments (do not include amount from line 10) . . . . . . . . . . ❿ 11

12 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿12

13 Total payments. Add lines 10, 11 and 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Refund or Balance Due

14 Amount overpaid. Subtract line 9 from line 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

15 Amount overpaid to be credited to 2001 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 15

16 Amount overpaid to be refunded. Subtract line 15 from line 14. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 16

17 Balance due. Subtract line 13 from line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

18 M-2220 penalty ❿ $ _____________ ; Other penalties ❿ $______________ ; . . . . . . . . . . . . . . . . . . . . . . . . Total penalty 18

19 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 19

20 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 20

Declaration

Under the penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my

knowledge and belief, it is true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which he/she has

knowledge.

Authorized signature

Social Security number

Title

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.

This return, together with payment in full, is due on or before March 15, 2001. Mail to: Massachusetts Department of Revenue, PO Box 7052,

Boston, MA 02204. Make remittance payable to: Commonwealth of Massachusetts.

Form code 379 Tax type 0116