Form Dexm - Domestic Companies Annual Report - 2012 Page 2
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5DEXM (12-12)
Page 2
SCHEDULE A
DOMESTIC LIFE INSURANCE COMPANIES
MUST BE COMPLETED BY ALL TAXPAYERS
PREMIUM TAX
STATE OF
NEW JERSEY BASIS
1 . Life Insurance Premium
2 . Individual Accident and Health
3 . Group Accident and Health
4 . All Other explain
5 . Total premiums per Schedule T (reconcile if different) lines 1 to 4
6 . Catchall attach computation
7 . Total Premiums (lines 5 and 6)
8 .
Dividends paid in cash: excluding $ ____________ dividends on Qualified Pension Plans
9
Dividends used for renewal: excluding $ _________ dividends on Qualified Pension Plans
10 .
Dividends left on deposit: excluding $ ___________ dividends on Qualified Pension Plans
11
Life premiums on qualifies pension plans (Attach documentation)
12 . All Other explain
13 .
Total deductions (lines 8 to 12) attach a copy of New Jersey State page of Annual
Statement as filed with the New Jersey Department of Banking and Insurance
14 . Taxable Premiums (line 7 less line 13)
TAX COMPUTATION
Type
TAXABLE PREMIUMS
Rate
Tax
(See Note Below)
15 . Life
$
2.1%
16 . Individual A & H
$
2.1%
17 . Group A & H
$
1.05%
18 . Total Tax (Lines 15 thru 17)
xxxxxx
$
CALCULATION OF TOTAL AMOUNT DUE
xxxxxxxxxxx
19 . Other Credits * -- Attach Supporting Documentation
20 .
21 . Guaranty Fund Assessment Credit (from Schedule C, Line 8 on Page 4)
Total Tax Credits (Total of Line 19 to line 21)
22 .
Balance of Tax Liability Due (Line 18 less line 22)
23 .
Credit for Prepayment of Premium Tax paid March 1 and June 1 of prior calendar year
24 .
Balance Due (Line 23 less line 24)
25 .
Prepayment of Tax liability due March 1st-- (50% of line 18)
26 .
Total Amount Due State of New Jersey (Line 25 plus line 26)
27 .
If line 25 plus line 26 is less than zero enter the amount of the overpayment
28 .
Amount of line 28 to be applied to Prepayment of Tax liability due June 1st
29 .
Amount of line 28 to be refunded (If Line 28 plus Line 29 is less than zero)
30 .
PAYMENT OF THE AMOUNT INDICATED AT LINE 27 MUST BE SUBMITTED TO THE DIVISION OF
TAXATION AT THE ADDRESS INDICATED ON THE FIRST PAGE OF THIS RETURN.
NOTE: If taxable premiums are determined as provided in N.J.S.A. 54:18A-6 (12 1/2% limitation), then Schedule B,
Calculation of Taxable Premiums as provided in N.J.S.A. 54:18-A-6 must be completed.
* Requires proof of payment
i.e. copies of cancelled checks
A copy of New Jersey State page, and, Schedule T as filed with the NAIC must be attached.
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