Form 314 - Annual Premium Tax Statement - Hawaii Department Of Commerce - 2008 Page 3
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1
2
3
4
5Name of Insurer
Round All Amounts to Nearest Dollar
EXHIBIT NO.:
3
INFORMATION:
Premium Tax Statement for the Year Ended December 31, 2008
APPLICABLE TO:
OCEAN MARINE INSURANCE ONLY
1.
Net Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ____________________
Gross premiums:
Direct premiums . . . . . . . . . . . .
$ _________________
Reinsurance assumed* . . . . . .
$ _________________
$ _________________
*[Complete Reinsurance Exhibit below]
Less:
Reinsurance ceded* . . . . . . . .
$ _________________
$ _________________
*[Complete Reinsurance Exhibit below]
2.
Less: Net losses paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ____________________
Gross losses paid:
Direct losses paid . . . . . . . . . .
$ _________________
(less salvage)
Losses paid on reinsurance
assumed . . . . . . . . . . . . . . . . .
$ _________________
$ _________________
Less: Recoveries on reinsurance ceded . . . . . . . . . . . . . . . .
$ _________________
3.
Gross Underwriting PROFIT Subject to Tax, item 1 minus item 2
(to line 3, page 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ____________________
(In the case of an insurer issuing participating contracts, such gross underwriting profit shall not include, for computation of
the tax, the amount refunded, or paid as participating dividends, by insurer to the holders of such contracts.)
NOTE: IF INSURER HAS OCEAN MARINE REINSURANCE ASSUMED AND/OR CEDED PREMIUMS,
COMPLETION OF THE REINSURANCE EXHIBIT BELOW IS REQUIRED.
REINSURANCE EXHIBIT
OCEAN MARINE REINSURANCE ASSUMED AND CEDED
REINSURANCE ASSUMED
REINSURANCE CEDED
NAIC
NAIC
Premiums
Complete Name of Direct
Premiums
Complete Name of
Co
Co
Paid
Writing Insurer
Received
Reinsurer
Code
Code
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
TOTAL . . . . . . . . . . . . . . . . . . .
$
TOTAL . . . . . . . . . . . . . . . . . .
$
COMPLETE EVERY ITEM OF EACH EXHIBIT. Enter “NONE” where no entries are to be made.
Page 3
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