Form Rct-122 - Gross Premiums Tax - Premiums Paid To Unauthorized Foreign Insurance Companies Page 3

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RCT-122
Revenue ID
PAGE 3 OF 3
(09-14)
Schedule A
Life Insurance and Annuities
Beginning
Policy
Type of
Amount of
Name of Insurance Company
Location of Risk
Date of Policy
Gross Premiums
Number
Insurance
Insurance
and Term
$
$
Total
Schedule B
Other Than Life Insurance and Annuities
Beginning
Policy
Type of
Amount of
Name of Insurance Company
Location of Risk
Gross Premiums
Date of Policy
Number
Insurance
Insurance
and Term
$
$
Total
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