Form Dl-1 - Premium Excise Return For Domestic Life Insurance Companies

Form Dl-1 - Premium Excise Return For Domestic Life Insurance Companies - 2004 Page 2

Part I. Premium Excise.

Activity for the year ending December 31, 2004.

Life insurance

Accident and health insurance

Jurisdictions where no

Massachusetts

insurance excise paid

Massachusetts

insurance excise paid

11 All new and renewal (direct) premiums for

❿

Massachusetts residents. . . . . . . . . . . . . . . . . . 1

12 Dividends applied to:

❿

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

❿

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

13 Total. Add lines 1 through 2b. . . . . . . . . . . . . . . 3

Deductions.

Include only what has been returned as receipts on this return or on a previous return.

14 Returned premiums but not including cash

❿

surrender values (attach schedule) . . . . . . . . . . 4

15 Premiums for company employees’ group

life and accident and health plans if included

❿

in line 1* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

16 Gross premiums for authorized preferred

❿

provider arrangements . . . . . . . . . . . . . . . . . . . 6

17 Dividends:

❿

a Paid in cash . . . . . . . . . . . . . . . . . . . . . . . . 7a

❿

b Applied in reduction of renewal premiums 7b

❿

c Left to accumulate at interest . . . . . . . . . . . 7c

❿

d Applied to purchase paid-up additions . . . . 7d

❿

e Applied to shorten premium paying period 7e

18 Total deductions. Add lines 4 through 7e . . . . . 8

19 Amount taxable. Subtract line 8 from line 3. . . . 9

10 Total life amount taxable. Add line 9, columns a and b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

11 Total accident and health amount taxable. Add line 9, columns c and d. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

*Premiums under the company employees’ group plans for annuity consideration and retirement benefits shall not be deducted.