Form Pf-Y - Annual Premium Tax Statement For A Foreign Insurance Company - Alabama Department Of Insurance Page 2
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1
2STATE OF ALABAMA DEPARTMENT OF INSURANCE
PF-Y
FOREIGN INSURANCE CASUALTY BUSINESS
for the period ending December 31, ____________
NAIC# _____________
NAME OF COMPANY
_____________________________________________________
PREMIUMS less DIVIDENDS & RETURNS
TAX RATE
TAX
1.
CASUALTY BUSINESS
(max. rate: 3.6%)
AOB---
X ______
=
$___________________
2.
HEALTH:
a)
GL50---
X .5%_
=
$___________________
Groups with less than 50 participants
b)
Other Health **
OH--
LESS:
MMP--
Medicare & Medicaid
Supplement policies
LESS:
EGP—
Employer sponsored Plans
for govt. employees
TOTAL TAXABLE OTHER HEALTH
TOP--
X 1.6%
=
$
.
=
$________________
3
GROSS PREMIUM TAX DUE:
4.
DEDUCTIONS
:
(must provide invoice and verification of payment)
a)
Ad valorem taxes paid on insurer’s principal office in AL $_______________________
$______________________
b)
Ad valorem taxes paid on property 50% occupied in AL
$_______________________
ADV----
Total 4a – 4c
c)
Ad valorem taxes paid directly or in the form of rent to
rd
a 3
party landlord on offices in AL, by square foot area $_______________________
$______________________
d)
All assessments paid during the year to the Alabama Health Insurance Plan (AHIP)
AHIP----
$______________________
e)
All examination expenses paid to the Alabama Commissioner of Insurance
EXAM---
$______________________
f)
60% of Alabama franchise and privilege taxes paid
FT---
$______________________
g)
20% of Guaranty Fund Assessments for each of 5 years following the year of payment
GFA---
$______________________
5.
Total Deductions (total of lines 4a – 4g)
Totaled--
6.
NET PREMIUM TAX DUE BEFORE CAPCO (
$_________________________
line 3 less 5; if 5 is greater, enter zero)
7.
LESS: CAPCO CREDIT AND/OR NEW MARKETS TAX CREDIT
$_________________________
*Only investors who have been allocated a premium tax credit pursuant to AL code
section 40-14B and/or Act 2012-483 are eligible for these credits.
8.
LESS: COASTAL CREDIT
$_________________________
*Only insurers who have obtained policies from AIUA and have been awarded
the credit pursuant to AL code section 27-1-24.1
9.
NET TAXES DUE AFTER CAPCO, COASTAL & New Markets CREDITS
$_________________________
(line 6 less lines 7 and 8)
10.
LESS: Quarterly Premium Tax Payments
$_________________________
11.
LESS: Prior Year Overpayment
$_________________________
PF----
$______________________
12.
PREMIUM TAX PAID (line 9 less lines 10 and 11)
**Line item 2b (tax-exempt premium only) require supporting documentation. A policy run, which can be obtained from the Company’s underwriting unit will suffice
as documentation.
Revised 10/6/2014
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