Form 63-23 - Premium Excise Return For All Classes Of Foreign Insurance Companies - 2003

Form 63-23

2003

Premium Excise Return

Massachusetts

for All Classes of Foreign Insurance Companies

Department of

Revenue

(Except Life Insurance Companies and Companies with Respect to Ocean Marine Business)

For calendar year 2003 or taxable year beginning

2003 and ending

Name of company

Federal Identification number

❿

❿

Mailing address

City/Town

State

Zip

Name of treasurer

Organized under the laws of

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.

Attach a copy of Schedule T of NAIC Annual Statement.

Use whole dollar method

❿ 1

11 Total net direct premiums for insurance of property or interests in Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12 Other (Fair Plan and Crime Prevention Premiums) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 2

13 Total income. Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

14 Dividend deduction. Premiums returned or credited to policyholders as dividends (unabsorbed premium deposits)

on direct business. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 4

15 Amount taxable. Subtract line 4 from line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

16 Tax at 2.28% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 6

17 Tax computed under retaliatory provisions (enter full amount). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 7

18 Credit recapture (attach Schedule H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 8

19 Applicable excise before credits. Enter the larger of line 6 plus line 8 or line 7 plus line 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

10 Enter 1.5% of company’s capital contribution in excess of your full proportionate share in the Massachusetts Property

and Casualty initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 10

11 Enter 10% of Mass. and Health Insurance Guaranty Association assessment paid in the prior years (see instructions) . . . ❿ 11

12 Economic Opportunity Area Credit (attach Schedule EOAC). Do not claim here if claimed on Form 63-29A . . . . . . . . . . . . . ❿ 12

13 Full Employment Credit (attach Schedule FEC). Do not claim here if claimed on Form 63-29A . . . . . . . . . . . . . . . . . . . . . . . ❿ 13

14 Low-Income Housing Credit (attach documentation). Do not claim here if claimed on Form 63-29A . . . . . . . . . . . . . . . . . . . ❿ 14

15 Excise due before voluntary contribution. Subtract the total of lines 10 through 14 from line 9. Not less than “0”. . . . . . . . . . . 15

16 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 16

17 Total excise plus voluntary contribution. Add lines 15 and 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 17

18 2002 overpayment applied to 2003 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 18

19 2003 estimated tax payments. Do not include amount from line 18 . . . . . . . . . . . . . . . . . . . . . . . ❿ 19

20 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 20

21 Total payments. Add lines 18 through 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

22 Amount overpaid. Subtract line 17 from line 21. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

23 Amount overpaid to be credited to 2004 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 23

24 Amount overpaid to be refunded. Subtract line 23 from line 22. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 24

25 Balance due. Subtract line 21 from line 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

26 M-2220 penalty ❿$ _______________________ ; Other penalties ❿$ ______________________ . . . . . . . . Total penalty 26

27 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 27

28 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 28

29 Are net direct premiums so reported in line 1?

Yes

No. Have all dividends claimed as a deduction in line 4 been

included as taxable premiums in line 1 on this return or on a previous Massachusetts return?

Yes

No.

Under the penalties of perjury, I declare that I have examined this return, including attachments, 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.

Signature of appropriate corporate officer (see instructions)

Social Security number

Telephone number

Date

❿

Signature of paid preparer

Employer Identification number

Address

Date

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

check here and attach Mass. Form M-2848, Power of Attorney.

The Privacy Act Notice is available upon request. Mail to: Massachusetts Department of Revenue, PO Box 7052, Boston, MA 02204. Make check or

money order payable to: Commonwealth of Massachusetts.