Form T-71 - Rhode Island And Providence Plantations Insurance Companies Tax Return Of Gross Premiums - 2014
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1
2State of Rhode Island and Providence Plantations
2014 Form T-71
14111699990101
Insurance Companies Tax Return of Gross Premiums
Name
Federal employer identification number
Insurance
Company
Address
State or country of incorporation or organization
Nonprofit Hos-
pital Service
Corp, Non-
profit Dental
Address 2
Company type: stock, mutual or participating
Corp, Non-
profit Medical
Service Corp
and HMO
City, town or post office
State
ZIP code
E-mail address
Amended
ATTACH LEGIBLE COPY OF SCHEDULE T AND SCHEDULE OF DIRECT BUSINESS IN THIS
Schedule A - Computation of Tax
STATE FROM THE ANNUAL STATEMENT SUBMITTED TO THE INSURANCE COMMISSIONER
1
a
Direct premiums (Gross premiums less return premiums from
Schedule T, Part 1 of Annual Statement to Insurance Commissioner)....
1a
b
Reinsurance assumed from companies not authorized to do business
in Rhode Island (covering property and risks in Rhode Island)............... 1b
2
TOTAL PREMIUMS. Add lines 1a and 1b .................................................................................................
2
Deductions
3
a
Dividends paid or credited to policyholders - Direct (Mutual & Mutual Plan
Companies Only).........................................................................................
3a
b
Federally exempt premiums. See instructions. (Gross premiums less
return premiums)..................................................................................... 3b
c
Capital investments deduction................................................................
3c
Tax Incentives for Employers deduction - RIGL §44-55. Attach Form RI-107
d
3d
4
TOTAL DEDUCTIONS. Add lines 3a, 3b, 3c and 3d.................................................................................
4
5
Tax and
Net taxable premium. Subtract line 4 from line 2.......................................................................................
5
Fee
6
a
Rhode Island tax. Multiply line 5 by the tax rate of 2% (0.02)................
6a
Amount
b
Retaliatory tax from page 2, Schedule B, line 3......................................
6b
7
TOTAL TAX DUE. Add lines 6a and 6b......................................................................................................
7
8
a
RI Credits from Schedule B-CR, Business Entity Credit Schedule, line 17
8a
b
Life and Health Guaranty Fee..................................................................
8b
9
TOTAL CREDITS. Add lines 8a and 8b.....................................................................................................
9
10
TAX AFTER CREDITS. Subtract line 9 from line 7. If zero or less, enter zero.........................................
10
11
FEES under Retaliatory Provisions from page 2, Schedule C, line 3.......................................................... 11
12
TOTAL TAX AND FEES DUE. Add lines 10 and 11...................................................................................
12
13
a
Payments made on 2014 BUS-EST, Business Tax Estimated Payment
13a
Payments
Other payments.......................................................................................
b
13b
14
TOTAL PAYMENTS. Add lines 13a and 13b..............................................................................................
14
15
Net tax due. Subtract line 14 from line 12..................................................................................................
15
Balance
Due
16
Interest due: (a) Late payment interest ___________ (b) Underestimating interest ___________ Total (a) + (b)
16
17
TOTAL DUE WITH RETURN. Add lines 15 and 16.................................................................................... 17
Overpayment. Subtract lines 12 and 16 from line 14.................................................................................
18
18
Refund
19
Amount of overpayment to be applied to 2015 estimated tax.....................................................................
19
20
Amount to be refunded. Subtract line 19 from line 18................................................................................ 20
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, accurate and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Authorized officer signature
Print name
Date
Telephone number
Paid preparer signature
Print name
Date
Telephone number
Paid preparer address
City, town or post office
State
ZIP code
PTIN
May the Division of Taxation contact your preparer? YES
Revised 09/2014
Key #13
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