Form Rct-121a - Gross Premiums Tax - Domestic Casualty, Fire Or Life Insurance Companies Page 2
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1
21211012205
Revenue ID
RCT-121A
(06-12)
PAGE 2 OF 2
ATTACH A COPY OF THE PENNSYLVANIA BUSINESS PAGE AND SCHEDULE T OF
THE ANNUAL REPORT FILED WITH THE PENNSYLVANIA INSURANCE DEPARTMENT
USE WHOLE DOLLARS ONLY
Casualty and Fire Insurance
1.
Gross Direct Premiums Received less Cancellations and Premiums Returned
1.
2.
Extraordinary Medical Benefit Premiums
2.
3.
Dividends to Policy Holders
3.
4.
Other Deductions (Attach Schedule)
4.
5.
Taxable Fire and Casualty Premiums (Line 1 minus Lines 2, 3 and 4)
5.
Life Insurance
6.
Gross Life Premiums (Direct Written Basis)
6.
7.
Dividends to Policy Holders
7.
8.
Other Deductions (Attach Schedule)
8.
9.
Taxable Life Premiums (Line 6 minus Lines 7 and 8)
9.
Accident and Health Insurance
10. Gross Direct Accident and Health Premiums
10.
11. Dividends to Policy Holders
11.
12. Other Deductions (Attach Schedule)
12.
13. Taxable Accident and Health Premiums (Line 10 minus Lines 11 and 12)
13.
14. Total Taxable Premiums (Add Lines 5, 9 and 13)
14.
15. Tax (Line 14 times tax rate - See Instructions)
15.
If registered with the PA Department of Insurance as a Casualty Insurance Company, enter Line 15 on Page 1, Line 1a. If registered with the
PA Department of Insurance as a Fire Insurance Company, enter Line 15 on Page 1, Line 1b. If registered with the PA Department of Insurance
as a Life Insurance Company, enter Line 15 on Page 1, Line 1c.
16.
16. State of Domicile
17.
17. NAIC Number
*1 21 1 01 2205*
Preparer’s Information:
Firm Name
Individual Preparer Name
Firm FEIN
Phone
Address
Email
City
Social Security Number
or PTIN
State
ZIP
I affirm under penalties prescribed by law this report, including any accompanying schedules and statements, has been prepared by me and to the best of my
knowledge and belief is a true, correct and complete report.
Signature of Preparer
Date
Signature of Preparer – Please sign after printing
Reset Entire Form
PRINT FORM
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