Form 314 - Annual Premium Tax Statement - Hawaii Department Of Commerce - 2008 Page 4
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5Name of Insurer
EXHIBIT NO.:
4
INFORMATION:
Premium Tax Statement for the Year Ended December 31, 2008
APPLICABLE TO:
ALL INSURERS
Round All Amounts to Nearest Dollar
DETAIL OF CREDITS AND PAYMENTS
PLEASE PROVIDE COMPLETE SUPPORT FOR ANY CREDIT TAKEN
CREDITS:
Hawaii Life & Disability Insurance Guaranty
Association Assessments . . . . . . . . . . . .
$ _NONE__________________
Tax Credit to Facilitate Regulatory Oversight
(If qualified---see HRS §431:7-207) . . . . . .
$ ________________________
___________________________________ . . .
$ ________________________
___________________________________ . . .
$ ________________________
___________________________________ . . .
$ ________________________
1.
TOTAL CREDITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________________________
(to line 5, page 1)
PAYMENTS:
Quarterly Premium Tax Payments for 2008:
Quarter Ended MARCH 31, 2008
$ ________________________
Quarter Ended JUNE 30, 2008
$ ________________________
Quarter Ended SEPTEMBER 30, 2008
$ ________________________
Quarter Ended DECEMBER 31, 2008
$ ________________________
AMENDED Quarter Ended ______________
$ ________________________
AMENDED Quarter Ended ______________
$ ________________________
AMENDED Quarter Ended ______________
$ ________________________
AMENDED Quarter Ended ______________
$ ________________________
TOTAL QUARTERLY Premium Tax Payments for 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$__________________________
2007 PRIOR YEAR Premium Tax Overpayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$__________________________
If AMENDED filing, amount paid with ORIGINAL filing . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$__________________________
2.
TOTAL PAYMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________________________
(to line 7, page 1)
COMPLETE EVERY ITEM OF EACH EXHIBIT. Enter “NONE” where no entries are to be made.
REMINDERS BEFORE MAILING:
1.
Tax Statement signed AND dated by a duly authorized officer of the Company?
2.
Total payments include the last quarterly tax payment? [December 31, 2008 - due January 31, 2009]
3.
Carry forward the correct prior year overpayment? If the Tax Statement was amended, carry
forward the amended prior year overpayment amount.
4.
ROUND TO NEAREST DOLLAR ALL AMOUNTS REPORTED ON THE TAX STATEMENT.
5.
Premium tax payments should be made payable to: DEPARTMENT OF COMMERCE AND
CONSUMER AFFAIRS (“DCCA”), STATE OF HAWAII.
6.
Pages 1 through 4 of the Tax Statement are required. File page 5 (Supplemental Schedule A) ONLY
if applicable --- if Schedule A is NONE, do not file page 5.
7.
Form must be on LEGAL SIZE PAPER --- LETTER SIZE WILL NOT BE ACCEPTED.
8.
Correct insurer address? ALL TAX RELATED CORRESPONDENCE from the Hawaii Insurance
Division will be sent to the address listed on page 1 of the Tax Statement.
Page 4
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