Form 74a110 - Kentucky Estimated Insurance Premiums Tax

74A110 (1-12)

WORKSHEET

Commonwealth of Kentucky

DEPARTMENT OF REVENUE

Estimated Tax for Calendar Year 2012



Report based on previous year’s liability.



Report based on current year estimate.

A. Taxable premiums on life and health policies ................................................................................................

$ __________________

B. Taxable premiums on other than life policies (excluding workers’ compensation policies) ........................... $ __________________

C. Total taxable premiums .................................................................................................................................... $ __________________

D. 1.

Total premiums tax liability for life insurance (multiply line C by 1.5%) ............................................... $ __________________

Total premiums tax liability for other than life insurance (multiply line C by 2%) ................................ $ __________________

E. 1.

Prior year credits ....................................................................................................................................... $ __________________

Guaranty Fund Assessment Credits .......................................................................................................... $ __________________

Total estimated tax liability (subtract line E from line D) ............................................................................... $ __________________

G. Total installment due June 1, 2012 (1/3 of line F) ...........................................................................................

$ __________________

H. Total installment due October 1, 2012 (1/3 of line F) .....................................................................................

$ __________________

Projected due March 1, 2013 (1/3 of line F) ....................................................................................................

$ __________________

DETACH BEFORE MAILING

74A110 (1-12)

KENTUCKY ESTIMATED

FOR OFFICIAL USE ONLY

Commonwealth of Kentucky

DEPARTMENT OF REVENUE

INSURANCE PREMIUMS TAX

1 0 1 2

___ ___ / ___ ___ ___ ___ / ___

Tax

Year

Tr.

Account Number ___ ___ ___ ___ ___

NAIC/

FEIN __ __ – __ __ __ __ __ __ __

TAX ID

AMENDED SECOND INSTALLMENT

Name of Company __________________________________________________________________________

For Calendar Year

Address (Number and Street) __________________________________________________________________

20____

City________________________________________________ State ______________ ZIP Code__________

(1) Amended

(2) Enter two-thirds

(3) Enter Tax Paid

(4) Amount of Tax

Tax

Estimated Tax

of Estimated Tax

With First Installment

Now Due

Code

A. Premiums tax on life

and health policies ..........................

B. Premiums tax on other than life

policies (excluding workers’

compensation policies) ....................

C. Retaliatory taxes and fees ...............

D. Total of lines A, B and C .............. ...

I, the undersigned, declare under the penalties of perjury, that I have examined these returns, including all accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct and complete.

____________________

___________________________________________

______________________

Date

Signature of Officer or Agent

Title of Officer



___________________________________________

______________________

Print or Type Name of Officer or Agent

Telephone Number