Form Gaa-2 - Transfer Of Clhiga Assessment Credit - 2014
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1Form GAA-2
Department of Revenue Services
2014
State of Connecticut
Transfer of CLHIGA Assessment Credit
(Rev. 12/14)
Complete this form in blue or black ink only.
Both an insurance company (transferee) to which a Connecticut Life and Health Insurance Guaranty Association (CLHIGA) assessment
credit was transferred and the CLHIGA member (transferor) by which the CLHIGA assessment credit was transferred must fi le this form
with their respective Form 207, Insurance Premiums Tax Return/Domestic Companies, or Form 207F, Insurance Premiums Tax
Return/Nonresident and Foreign Companies, on or before March 1, 2015.
Transferor’s name
Transferee’s name
Transferor’s Connecticut Tax Registration Number
Transferee’s Connecticut Tax Registration Number
Instructions for Transferor
Instructions for Transferee
Enter the transferor’s name and Connecticut Tax Registration
Enter the transferee’s name and Connecticut Tax Registration
Number above. The transferor must enter information about the
Number above. An authorized offi cer of the transferee must sign and
transferred CLHIGA assessment credit from Part 2 of its 2014
date the four copies of the 2014 Form GAA-2 that were delivered
Schedule GAA, Insurance Guaranty Association Credit. An
to the transferee by the transferor. The transferee must report on
authorized offi cer of the transferor must sign and date four copies
its 2014 Schedule GAA, Part 4, the information entered on the
of the 2014 Form GAA-2, Transfer of CLHIGA Assessment Credit,
2014 Form GAA-2. The transferee must attach one signed copy
and must deliver them to the transferee. Once those copies are
of the 2014 Form GAA-2 to the transferee’s 2014 Form 207 or
signed and dated by the transferee, and the transferee returns two
Form 207F and retain the other copy for its records. The transferee
signed copies to the transferor, the transferor must attach one copy
must return the other two signed copies of the 2014 Form GAA-2
to the transferor’s 2014 Form 207 or Form 207F and retain the other
to the transferor.
copy for its records.
Complete a 2014 Form GAA-2 only to report a transfer of a CLHIGA assessment credit for calendar year 2014. Do not complete a subsequent
year (2015 or later) Form GAA-2 to report a transfer of a CLHIGA assessment credit for calendar year 2014.
The transferor named above hereby assigns the credit described below to the transferee named above. This credit may be taken only against
the transferee’s insurance premiums tax liability. The transferee is an affi liate, as defi ned in Conn. Gen. Stat. §38a-1, of the transferor. This
transfer does not affect the obligation of the transferor to pay to the Department of Revenue Services (DRS) any sums acquired by refund
from CLHIGA under Conn. Gen. Stat. §38a-866(f) that are required to be paid to DRS in accordance with Conn. Gen. Stat. §38a-866(h)(1).
____________________________________________________
____________________________________________________
Signature of authorized offi cer of transferor
Date
Signature of authorized offi cer of transferee
Date
____________________________________________________
____________________________________________________
Print name of authorized offi cer
Print name of authorized offi cer
____________________________________________________
____________________________________________________
Print title of authorized offi cer
Print title of authorized offi cer
No entries should be made as negative amounts.
A
B
D
E
C
Assessment
Name of Insolvent
Assessment Amount Paid
20% (.20) of Amount
Calendar
Date
Insurer
During Column C Calendar Year
Entered in Column D
Year
1
11/1/2008
Lincoln Memorial Life Ins. Co.
2009
$
$
2
2/2/2009
Administrative assessment
2009
$
$
3
2/1/2010
Administrative assessment
2010
$
$
4
2/1/2011
Administrative assessment
2011
$
$
5
1/2/2012
Administrative assessment
2012
$
$
6
1/1/2013
Administrative assessment
2013
$
$
7
5/15/2013
Lumberman’s Mutual Casualty Co.
2013
$
$
8
6/12/2013
Executive Life Ins. Co. of NY
2013
$
$
9
Add Lines 1 through 8.
$
The amounts on Lines 1 through 8 should agree with the amounts on the:
•
Transferor’s 2014 Schedule GAA, Part 2, Lines 1 through 8; and
•
Transferee’s 2014 Schedule GAA, Part 4, Lines 1 through 8.
For Further Information
For further information on the insurance premiums tax, call the Public Services Audit unit at 860-541-3225 during business hours
Monday through Friday, 8:30 a.m. to 4:30 p.m.
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