Form Ins-5 - Fire Investigation And Prevention Tax - 2003

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*0331100*
FORM INS-5
FIRE INVESTIGATION
AND PREVENTION TAX
2003
00
ANNUAL/RECONCILIATION RETURN
*0331100*
Account ID No.
Period Begin
Period End
Due Date
Entity Information:
Check here if you made estimate
payments during the year
This return is made in compliance with the provisions of 25 M.R.S.A. § 2399. The amount of all GROSS DIRECT PREMIUMS or assessments for fire risks written in the State of
Maine during the year ending December 31, 2003 was as follows:
COMPUTATION OF TAX ON FIRE PREMIUMS
1
2
3
4
5
Line of Business
Premiums
Premiums Returned
Net
% of Premiums
Amount of Premiums
Direct Writings
Dividends Paid
Premiums
Allocated to Fire
Allocated to Fire
or Assessments
(column 3 x column 4)
,
,
Fire ........................................... $ _______________ $ _________________ $ __________________
__________________ %
$
.00
,
,
Inland Marine ............................ $ _______________ $ _________________ $ __________________
__________________ %
$
.00
,
,
Aircraft Physical Damage .......... $ _______________ $ _________________ $ __________________
__________________ %
$
.00
Auto Physical Damage:
Comprehensive – Full Coverage
(covers 001, 004, 061, etc.)
$
,
,
.00
Private ................................... $ _______________ $ _________________ $ __________________
__________________ %
$
.00
,
,
Commercial ............................ $ _______________ $ _________________ $ __________________
__________________ %
Comprehensive – All Deductibles:
(covers 003, 005, 010, 062, 065, etc.)
,
,
$
.00
Private ................................... $ _______________ $ _________________ $ __________________
__________________ %
,
,
$
.00
Commercial ............................ $ _______________ $ _________________ $ __________________
__________________ %
Fire and Theft:
(covers 012, 033)
,
,
.00
$
Private ................................... $ _______________ $ _________________ $ __________________
__________________ %
,
,
.00
$
Commercial ............................ $ _______________ $ _________________ $ __________________
__________________ %
Fire, Theft and Misc.:
(covers 020, 021, 031, 034, 035, 036, etc.)
$
,
,
.00
Private ................................... $ _______________ $ _________________ $ __________________
__________________ %
$
,
,
.00
Commercial ............................ $ _______________ $ _________________ $ __________________
__________________ %
$
,
,
.00
Home Owners Policies .............. $ _______________ $ _________________ $ __________________
__________________ %
$
,
,
.00
Commercial Multiple Peril .......... $ _______________ $ _________________ $ __________________
__________________ %
$
,
,
.00
Any Others ............................. $ _______________ $ _________________ $ __________________
__________________ %
,
,
$
.00
1. Total of amounts entered in column 5 ....................................................................................... ............................................... 1.
INS-5 Rev. 08/03

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