Form 314 - Annual Premium Tax Statement - Hawaii Department Of Commerce - 2008 Page 2
ADVERTISEMENT
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5Name of Insurer
Round All Amounts to Nearest Dollar
EXHIBIT NO.:
1
INFORMATION:
Premium Tax Statement for the Year Ended December 31, 2008
APPLICABLE TO:
ALL INSURANCE (EXCEPT OCEAN MARINE AND LIFE INSURANCE)
INCLUDE ACCIDENT AND HEALTH PREMIUMS UNDER THIS EXHIBIT
1.
Gross premiums written from all risks or property resident, situated, or
located within Hawaii. Except for Surety and group insurance contracts,
all fees, charges or other consideration charged for the insurance or for the
procurement thereof must be included (Section 431:10-218, Hawaii Revised Statutes).
From direct writings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ __________________
2.
LESS:
Other, if any (explain - ____________________________) . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ __________________
(Attach additional sheets if needed)
3.
PREMIUMS SUBJECT TO TAX, item 1 minus 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ __________________
(to line 1, page 1)
4.
Were all fees, charges or other consideration charged for the insurance or for the procurement thereof included in the
premium total?
(Include installment charges or fees collected or received by insurer)
Yes
Amount: ________________________
No
Amount: ________________________
EXHIBIT NO.:
2
Premium Tax Statement for the Year Ended December 31, 2008
INFORMATION:
APPLICABLE TO:
LIFE INSURANCE ONLY
5.
Gross premiums, exclusive of consideration paid for annuities,
received from all risks resident within Hawaii. Except for group
insurance contracts, all fees, charges or other consideration charged
for the insurance or for the procurement thereof must be included
(Section 431:10-218, Hawaii Revised Statutes).
From direct writings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________________
6.
Premiums for insurance written, procured or received in Hawaii on
individuals residing outside Hawaii on which comparable tax has not
been paid to another appropriate taxing authority . . . . . . . . . . . . . .
$ _________________
(Section 431:7-202(b), Hawaii Revised Statutes)
7.
TOTAL GROSS PREMIUMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________________
8.
LESS:
a. Dividends paid or credited to policyholders . . . . . . . . . . . . . . . . .
$ _________________
b. Other, if any (explain - ____________________________) . . . . . .
$ _________________
(Attach additional sheets if needed)
9.
TOTAL DEDUCTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________________
10.
PREMIUMS SUBJECT TO TAX, item 7 minus 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ _________________
(to line 2, page 1)
COMPLETE EVERY ITEM OF EACH EXHIBIT. Enter “NONE” where no entries are to be made.
Page 2
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