Form Ib-13 - Gross Premium Tax Return Life, Accident, Health And Title Companies
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3IB-13
Gross Premium Tax Return
Life, Accident, Health and Title Companies
Web
12-12
North Carolina Department of Revenue
DOR Use Only
For tax year beginning
and ending
(MM-DD-YY)
(MM-DD-YY)
Legal Name (First 35 Characters)
(USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
Federal Employer ID Number
Mailing Address
City
State
Zip Code
NCDOR ID Number
Name of Contact Person
Phone Number
State of Domicile
Fill in circle if applicable:
NAIC Number
Payment has been made through electronic funds transfer (EFT)
Amended Return
Date of Withdrawal if Company Surrendered Certificate of Authority to do Business in NC During the Year
Schedule A. Summary of Amount Due
,
,
,
.
Total 2012 Gross Premium Tax Liability Due
1.
00
1.
(From Schedule B, Part 3, Line 10)
,
,
,
.
Total 2012 Insurance Regulatory Charge Due
2.
00
2.
(From Schedule C, Line 7)
,
,
,
.
$
Total Payment Due for 2012
3.
$
3.
00
Add Line 1 and Line 2
The following must be attached to this return:
2012 Schedule T from the Annual Statement
2012 North Carolina Business Page
The following must be attached if applicable (check all that apply):
Reconciliation schedule explaining any differences in the premiums listed on the tax return, the North Carolina
Business Page, and Schedule T
2012 Guaranty Assessment Tax Credit Available notice from either the North Carolina Life & Health Insurance
Guaranty Association or the North Carolina Insurance Guaranty Association
Schedule in support of any supplemental workers’ compensation tax credits claimed
Form CD-425, NC-478 and applicable series schedules in support of Article 3A, low-income housing, and mill
rehabilitation tax credits claimed
Signature:
Title:
Date:
I certify that, to the best of my knowledge, this return is accurate and complete.
Returns are due by the 15th day of the 3rd month following the end of the calendar year. Your check or money
order must be in the form of U.S. currency from a domestic bank.
N.C. Department of Revenue, Insurance Premium Tax Unit, P.O. Box 25000, Raleigh, NC 27640-0300
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