Form 63-20-23 - Premium Excise Return For Foreign Life Insurance Companies On Life, Accident And Health Business - 2000 Page 2

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Part I. Premium Excise

Life Premiums

Income

11 All new and renewal direct premiums for all policies of life insurance allocable to Massachusetts . . . . . . . . . . . . . . . . . . . . . ❿ 1

12 Dividends applied to:

a Purchase paid-up additions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 2a

b Shorten premium paying period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 2b

13 Total gross direct premiums. Add lines 1, 2a and 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Deductions

14 Returned premiums but not including cash surrender values. . . . . . . . . . . . . . . . . . . . ❿ 4

(Itemized supporting schedule is required as part of line 4)

15 Dividends:

a Paid in cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 5a

b Applied in reduction of renewal premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 5b

c Left to accumulate at interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 5c

d Applied to purchase paid-up additions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 5d

e Applied to shorten premium paying period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 5e

16 Total deductions. Add lines 4 through 5e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Taxable amount

17 Taxable amount. Subtract line 6 from line 3

(Enter line 7 in line 1 in Computation of Excise) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Accident and Health Premiums

Income

18 Total net direct premiums for insurance of property or interests in Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 8

Deductions

19 Dividend deduction. Premiums returned or credited to policyholders as dividends

(unabsorbed premium deposits) on direct business . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 9

10 Premium deduction. Gross premiums for authorized Preferred Provider arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 10

11 Total deductions. Add line 9 and line 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Taxable amount

12 Taxable amount. Subtract line 11 from line 8

(Enter line 12 in line 4 in Computation of Excise) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Part II. Computation of Retaliatory Tax

Use the space below to calculate your excise using the identical method and the same rate used by the state in which you are incorporated in taxing a like

Massachusetts insurance company, or its agents, if doing business to the same extent. If the computation in the state of your incorporation is in every respect

the same as your Massachusetts computation, a statement to that effect should be made.

Column A. Life computation

Column B. Accident and health computation