Form Rct-121b - Gross Premiums Tax Report - Foreign Life Or Foreign Title Insurance Companies Page 3

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1212012305
Revenue ID
RCT-121B
PAGE 3 OF 3
(09-14)
RETALIATORY WORKSHEET - SCHEDULE OF TAXES, ASSESSMENTS,
LICENSES AND FEES
PENNSYLVANIA
USE WHOLE DOLLARS ONLY
STATE OF DOMICILE
Premiums Taxes
1.
Fire, Casualty and Title Premiums Tax
1a.
1b.
2.
Ocean Marine Gross Profit Tax
2a.
2b.
3.
Life Premiums Tax
3a.
3b.
4.
Annuities Tax
4a.
4b.
5.
Accident and Health Premiums Tax
5a.
5b.
6.
Reinsurance Assumed from
Unauthorized Companies
6a.
6b.
7.
Other Taxes (Add schedule itemizing
by type)
7a.
7b.
8.
Worker’s Compensation Assessments
(Add schedule itemizing by type)
8a.
8b.
9.
Other Assessments (Add schedule
itemizing by type)
9a.
9b.
10. Licenses and Fees (Annual basis, add
schedule itemizing by type)
10a.
10b.
11. Totals (Add Line 1 through Line 10)
11a.
11b.
12. Retaliatory payable to the PA Department of Revenue (11b minus 11a)
12.
13. How many agents are licensed to represent your company in Pennsylvania during
the tax year?
13.
14. What are your state fees for licensing agents of similar Pennsylvania insurers?
14.
15. Are the fees in Line 14 imposed on the company (enter “A”) or the agent
(enter “B”)?
15.
Reset Entire Form
RETURN TO PAGE 1
PRINT FORM
1212012305
1212012305
1212012305

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