Form 207f - Insurance Premiums Tax Return Nonresident And Foreign Companies

Form 207F

Department of Revenue Services

2014

State of Connecticut

Insurance Premiums Tax Return

PO Box 2990

Hartford CT 06104-2990

Nonresident and Foreign Companies

(Rev. 12/14)

Complete this return in blue or black ink only.

General Information

D. If this is a ﬁ nal return, is the insurance company:



Check if this is an amended return.



No longer licensed in Connecticut; out of business



B. Change of:

Address



Merged/reorganized



_______________________





Domicile, enter new domicile: ___________________

Enter survivor’s CT Tax Registration No.

E. The insurance company is currently in:

C. If this is a short period,





 Receivership



Rehabilitation

enter period covered by this return: __________________________

Connecticut Tax Registration Number

Name of company



Taxpayer

Date received (DRS use only)

Address

Number and street

PO Box



Type

Federal Employer ID Number (FEIN)



City or town

State

ZIP code

Organized under the laws of



 1



Enter gross direct premiums received during the calendar year. See instructions.



Dividends paid: See instructions.

Net direct premiums received during the year from ocean marine insurance policies written on property



located in this state



Beneﬁ t payments from group health insurance premiums to the extent allowed by Conn. Gen. Stat. §12-210a

 5



Total deductions: Add Lines 2, 3, and 4.

 6



Taxable premiums: Subtract Line 5 from Line 1.

7



Multiply Line 6 by 1.75% (.0175).

 8



Taxes and other obligations on retaliatory basis: See instructions.

 9



Other obligations paid to Connecticut: See instructions.

 10

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10 Retaliatory computation: Subtract Line 9 from Line 8.

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11 Tax: Enter Line 7 or Line 10 amount, whichever is greater.

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12 Enter amount from Form CT-207K, Part 4, Line 36, Column C.

 13

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13 Enter CIGA assessment credit. See instructions.

 14

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14 Enter CLHIGA assessment credit. See instructions.

 15

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15 Total credits: Add Lines 12, 13, and 14.

 16

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16 Net tax: Subtract Line 15 from Line 11. If less than zero, enter “0.”

 17

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17 Overpayment applied from prior year

 18

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18 Payments made with estimated tax payment coupons Forms 207F ESA, ESB, ESC, and ESD

 19

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19 Payments made with extension request Form 207F EXT

 20



20 Total prior payments: Add Lines 17, 18, and 19.

 21



21 If Line 20 is greater than Line 16, enter amount overpaid.



22 Amount to be: credited to 2015 estimated tax

(22a) $

refunded

(22b) $

For faster refund, use Direct Deposit by completing Lines 22c, 22d, and 22e.





22c. Checking

Savings

22d. Routing number





22e.

Account number

22f. Will this refund go to a bank account outside the U.S.?

Yes



23 If Line 16 is greater than Line 20, enter amount owed.

24 If late: penalty (24a) $

plus interest (24b) $

See instructions.





25 Interest on underpayment of estimated tax: Attach Form 207

. See instructions.

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26 Balance due with this return. Make check payable to Commissioner of Revenue Services.

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, 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

Sign Here

Print name of principal ofﬁ cer

Telephone number

(

)

Keep a copy

Email address of principal ofﬁ cer

of this return

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