Form Ip-1 - Vermont Insurance Premium Tax Return
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1
2Vermont Department of Taxes, 133 State Street, PO Box 547, Montpelier, VT 05601-0547
Telephone: (802) 828-2551
F
orm
V
VERMONT INSURANCE PREMIUM TAX RETURN
ermont
IP-1
For tax year ___________
Return due annually on or before the last day of February.
B.
C.
A.
Print or type complete name and address below:
Date Organized:
NAIC #
D.
State of Domicile
E.
Fed. ID #
F.
Date first licensed to conduct business in VT:
Property & Casualty - Computation of Insurance Premium Tax on all business reported on Schedule T by Property and Casualty
Companies. (Life, Accident & Health and Annuity on reverse side.) Please refer to Form IP-1 instructions to ensure the tax return is
completed accurately.
Column A
Column B
State of Domicile
State of Vermont
1. Gross direct Property & Casualty premiums written in Vermont during the year 1.
$
$
2. For Vermont companies - Enter the total gross direct premiums written
outside of VT which are not taxed by other state(s).
2.
3. Total Gross Direct Premiums
3.
4. Dividends paid or credited to policyholders.
4.
5. Other Deductions (List or attach a schedule and enter in the total.)
5.
6. Total Allowable Deductions
6.
7. Taxable Property & Casualty Premiums
7.
8. Property & Casualty tax liability at rate of _______ %
(Insert state of domicile tax percentage)
8.
9. Property & Casualty tax liability at rate of 2% for Vermont
9.
10. Life, Accident & Health and Annuity Tax from Line 38
10.
11. Total Premium Tax
11.
12. Total Estimated Premium Payments
12.
13. For Vermont Companies - Tax Credits
13.
14. For Vermont Companies - Tax Liability, see instructions
14.
15. Overpayment - see instructions
15.
16. Amount of overpayment to apply toward next year’s estimated tax
16.
17. Refund Due - Amount of overpayment to refund
17.
18. Balance Due - see instructions
Make check payable to: VERMONT DEPARTMENT OF TAXES
18.
G.
SIGNATURE REQUIRED. UNSIGNED TAX RETURNS WILL BE RETURNED.
I hereby certify that this return is true, correct and complete to the best of my knowledge.
Signature of Responsible Officer
Printed Name
Title
Date
Signature of Preparer Other Than Officer
Printed Name
Title
Date
Title/Firm Name
Preparer’s Telephone Number
Date
PI
Form IP-1
Rev. 10/11
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