Form Rct-121b - Gross Premiums Tax-Foreign Life Or Foreign Title Insurance Companies Page 2
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1
2
31212012205
Revenue ID
RCT-121B
(09-14)
PAGE 2 OF 3
ATTACH A COPY OF THE PENNSYLVANIA BUSINESS PAGE AND SCHEDULE T OF
THE ANNUAL REPORT FILED WITH THE PENNSYLVANIA INSURANCE DEPARTMENT
USE WHOLE DOLLARS ONLY
Title Insurance
1.
Gross Direct Title Premiums Received less Cancellations and Premiums Returned
1.
2.
Approved Attorney Fees (See Instructions)
2.
3.
Dividends to Policy Holders
3.
4.
Other Deductions (Attach Schedule)
4.
5.
Taxable Title Insurance Premiums (Line 1 or Line 2 minus Lines 3 and 4)
5.
Life Insurance
6.
Gross Life Premiums (Direct Written Basis)
6.
7.
Dividends to Policy Holders
7.
8.
Other Deductions (Attach Schedule)
8.
9.
Taxable Life Insurance Premiums (Line 6 minus Lines 7 and 8)
9.
Accident and Health Insurance
10. Gross Direct Accident and Health Premiums
10.
11. Dividends to Policy Holders
11.
12. Other Deductions (Attach Schedule)
12.
13. Taxable Accident and Health Insurance Premiums (Line 10 minus Lines 11 and 12)
13.
14. Total Taxable Premiums (Add Lines 5, 9 and 13)
14.
15. Tax (Line 14 times tax rate - See Instructions)
15.
16. Retaliatory (from Page 3, Line 12)
16.
If registered with the PA Department of Insurance as a Foreign Life Insurance Company, enter Line 15 on Page 1, Line 1a and enter Line 16
on Page 1, Line 1b. If registered with the PA Department of Insurance as a Foreign Title Insurance Company, enter Line 15 on Page 1, Line 1c,
and enter Line 16 on Page 1, Line 1d.
17. State of Domicile
17.
18. NAIC Number
18.
1212012205
Preparer’s Information:
Firm Name
Individual Preparer Name
Firm FEIN
Phone
Address
Email
City
Social Security Number
or PTIN
State
ZIP
I affirm under penalties prescribed by law this report, including any accompanying schedules and statements, has been prepared by me and to the best of my
knowledge and belief is a true, correct and complete report.
Signature of Preparer
Date
Signature of Preparer – Please sign after printing
Reset Entire Form
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