Form 207c - Insurance Premiums Tax Return Captive Insurance Companies - 2014
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1
2Department of Revenue Services
Form 207C
2014
State of Connecticut
PO Box 2990
Insurance Premiums Tax Return Captive Insurance Companies
Hartford CT 06104-2990
Complete this return in blue or black ink only.
(Rev. 12/14)
Taxpayer Name
Connecticut Tax Registration Number
Taxpayer
Address
Number and Street
PO Box
Federal Employer ID Number (FEIN)
Type
or
Print
City or Town
State
ZIP Code
Date Received (DRS Use Only)
Check if you are fi ling as a sponsored captive insurance company and enter the number of protected cells covered by this return:
A.
_________________
Check if you are fi ling a consolidated return for two or more companies and enter the number of companies included in this return:
B.
_________________
Check if this is an amended return.
C.
Computation of Tax Due on Insurance
1.
1. Gross direct premiums collected or contracted for ...................................................................................
00
2.
2. Other charges (specify:
) ......
00
_________________________________________________________________________________________________________________________________
3.
3. Total Premiums: Add Lines 1 and 2 .........................................................................................................
00
4.
4. Return Premiums .....................................................................................................................................
00
5. Other deductions (specify:
) ......
5.
00
___________________________________________________________________________________________________________________________
6.
6. Total Deductions: Add Lines 4 and 5 .......................................................................................................
00
7.
7. Net Taxable Premiums: Subtract Line 6 from Line 3................................................................................
00
8.
8. Tax on Direct Insurance Premiums from Tax Rate Schedule (Direct Rate) .............................................
00
9.
9. Tax on Reinsurance Premiums from Line 25 ...........................................................................................
00
10.
10. Total Tax: Add Lines 8 and 9 ...................................................................................................................
00
11. Enter the amount from Line 10
If Line 10 is more than $200,000, enter $200,000; or
11.
If Line 10 is less than $7,500, enter $7,500; ............................................................................................
00
12.
12. If this is the fi rst year of license in Connecticut, enter $7,500.00 .............................................................
00
13.
13. Net tax: Subtract Line 12 from Line 11. If less than zero, enter zero “0” ..................................................
00
14.
14. Payments made with extension request Form 207C EXT........................................................................
00
15.
15. Subtract Line 14 from Line 13 ..................................................................................................................
00
16. If late: penalty
(16a) $ _______________ plus interest
(16b) $ ________________ See instructions 16.
00
17.
17. Balance due with this return
00
Computation of Tax Due on Reinsurance
18. Assumed Reinsurance Premiums collected or contracted for..................................................................
18.
00
19. Other charges (please specify) ................................................................................................................
19.
00
20. Total Assumed Reinsurance Premiums: Add Lines 18 and 19 .................................................................
20.
00
21. Return premiums ......................................................................................................................................
21.
00
22. Other deductions (please specify) ............................................................................................................
22.
00
23. Total Deductions: Add Lines 21 and 22 ....................................................................................................
23.
00
24. Net Assumed Reinsurance Premiums: Subtract Line 23 from Line 20 ....................................................
24.
00
25. Enter amount due from Tax Rate Schedule (Assumed Rate) ..................................................................
25.
00
Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) and, to the best of my knowledge and
belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or document to DRS is a fi ne of not more than $5,000, or imprisonment
for not more than fi ve years, or both. The declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge.
Signature of principal offi cer
Title
Date
Print name of principal offi cer
Telephone number
Sign Here
(
)
Keep a copy
Email address of principal offi cer
of this return
for your
Paid preparer’s signature
Date
Preparer’s SSN or PTIN
records.
Firm’s name and address
FEIN
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