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Michigan Department of Treasury

4906 (Rev. 02-14), Page 1

2014 Insurance Company Amended Return

for Corporate Income and Retaliatory Taxes

Issued under authority of Public Act 38 of 2011.

2. Federal Employer Identification Number (FEIN)

1. Taxpayer Name

Address (Number, Street)

Reason code for amending (see instr.)

Check if

Foreign Insurer

City

State

ZIP/Postal Code

Country Code 4. State of Incorporation (use 2 letter abbreviation)

A. As Originally Filed

GROSS DIRECT PREMIUMS WRITTEN IN MICHIGAN

or Previously Amended

B. Correct Amount

5. Gross direct premiums written in Michigan...................................................

6. Premiums on policies not taken....................................................................

7. Returned premiums on canceled policies.....................................................

8. Receipts on sales of annuities ......................................................................

9. Receipts on reinsurance assumed (see instructions) ...................................

10. Add lines 6, 7, 8 and 9. ................................................................................. 10.

11. Direct Premiums Written in Michigan. Subtract line 10 from line 5.

If less than zero, enter zero .......................................................................... 11.

DISABILITY INSURANCE EXEMPTION

12. Disability insurance premiums written in Michigan, not including credit or

disability income insurance, OR $190,000,000, whichever is less ............... 12.

13. Gross direct premiums from all lines of insurance carrier services

received everywhere .................................................................................... 13.

280,000,000

14. Phase out ..................................................................................................... 14.

15. Subtract line 14 from line 13. If less than zero, enter zero .......................... 15.

16. Exemption reduction. Multiply line 15 by 2 ................................................... 16.

17. Subtract line 16 from line 12. If less than zero, enter zero ........................... 17.

18. Adjusted Tax Base. Subtract line 17 from line 11 ......................................... 18.

19. Tax Before Credits.

Multiply line 18 by 1.25% (0.0125) ............................................................... 19.

CREDITS

20. Enter amounts paid from 1/1/2013 to 12/31/2013 to each of the following:

a. Michigan Workers’ Compensation Placement Facility ........................... 20a.

b. Michigan Basic Property Insurance Association .................................... 20b.

c. Michigan Automobile Insurance Placement Facility .............................. 20c.

d. Property and Casualty Guaranty Association ........................................ 20d.

e. Michigan Life and Health Insurance Guaranty Association ................... 20e.

21. Add lines 20a through 20e............................................................................ 21.

22. a. Michigan Examination Fees .................................................................. 22a.

b. Credit. Multiply line 22a by 50% (0.50) .................................................. 22b.

23. Tax liability before recapture. Subtract lines 21 and 22b from line 19.

If less than or equal to $100, enter zero ....................................................... 23.

24. Recapture. Enter amount from Form 4902, line 20 ...................................... 24.

25. Total Michigan Tax. Add lines 23 and 24 .................................................... 25.

WITHOUT PAYMENT: Mail return to:

WITH PAYMENT: Pay amount on

Make check payable to “State of

line 55 and mail check and return to:

Michigan.” Print taxpayer’s FEIN, the

tax year, and “CIT” on the front of the

Michigan Department of Treasury

check. Do not staple the check to the

PO Box 30803

PO Box 30804

return.

Lansing MI 48909

0000 2014 40 01 27 7

Continue and sign on Page 2

Form 4906 - Insurance Company Amended Return For Corporate Income And Retaliatory Taxes

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