Form Gaa-1 - Transfer Of Ciga Assessment Credit - 2014
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1Department of Revenue Services
Form GAA-1
2014
State of Connecticut
Transfer of CIGA Assessment Credit
(Rev. 12/14)
Complete this form in blue or black ink only.
Both an insurance company (transferee) to which a Connecticut Insurance Guaranty Association (CIGA) assessment credit was transferred
and the CIGA member (transferor) by which the CIGA 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
Number above. The transferor must enter information about
above. An authorized offi cer of the transferee must sign and date
the transferred CIGA assessment credit from Part 1 of its 2014
the four copies of the 2014 Form GAA-1 that were delivered to the
Schedule GAA, Insurance Guaranty Association Credit. An
transferee by the transferor. The transferee must report on its 2014
authorized offi cer of the transferor must sign and date four copies
Schedule GAA, Part 3, the information entered on the 2014 Form
of the 2014 Form GAA-1, Transfer of CIGA Assessment Credit, and
GAA-1. The transferee must attach one signed copy of the 2014
must deliver them to the transferee. Once those copies are signed
Form GAA-1 to the transferee’s 2014 Form 207 or Form 207F and
and dated by the transferee, and the transferee returns two signed
retain the other copy for its records. The transferee must return the
copies to the transferor, the transferor must attach one copy to the
other two signed copies of the 2014 Form GAA-1 to the transferor.
transferor’s 2014 Form 207 or Form 207F and retain the other copy
for its records.
Complete a 2014 Form GAA-1 only to report a transfer of a CIGA assessment credit for calendar year 2014. Do not complete a subsequent
year (2015 or later) Form GAA-1 to report a transfer of a CIGA 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 CIGA under Conn. Gen. Stat. §38a-841(2) that are required to be paid to DRS in accordance with Conn. Gen. Stat. §38a-841(a)(3)(A).
__________________________________________________________
__________________________________________________________
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
C
D
E
Assessment
Name of Insolvent
Calendar
Assessment Amount Paid During
20% (.20) of Amount
Date
Year
Column C Calendar Year
Entered in Column D
Insurer
1
12/22/2008
Home Insurance Co.
2009
$
$
2
12/22/2009
Covenant Mutual Ins. Co. et al.
2009
$
$
3
12/22/2009
Covenant Mutual Ins. Co. et al.
2010
$
$
4
12/27/2010
Villanova Insurance Co. et al.
2010
$
$
5
12/27/2010
Villanova Insurance Co. et al.
2011
$
$
6
12/29/2011
American Universal Ins. Co. et al.
2011
$
$
7
12/29/2011
American Universal Ins. Co. et al.
2012
$
$
8
12/20/2012
Employers Casualty Co. et al.
2012
$
$
9
12/20/2012
Employers Casualty Co. et al.
2013
$
$
10
Add Lines 1 through 9.
$
The amounts on Lines 1 through 9 should agree with the amounts on the:
•
Transferor’s 2014 Schedule GAA, Part 1, Lines 1 through 9; and
•
Transferee’s 2014 Schedule GAA, Part 3, Lines 1 through 9.
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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