Form Tc-49 - Insurance Premium Tax Return - 2009 Page 2
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Utah Insurance Premium Tax Return — Schedule A
TC-49A (TC-49_2) Rev. 12/09
Annual Report Totals.
Include an 8 1/2" x 11" copy of the Utah business page and/or Schedule T of the Annual Report with this return.
1. Life insurance companies. Enter the total from the Utah business page. .................................
1
$
00
2. Property and casualty insurance companies. Enter the total from the Utah business page. ....
2
$
00
3. Other insurance companies. Enter the total amount from your annual statement of
premiums written in Utah. ........................................................................................................
3
$
00
Premiums received from direct business in Utah
Deductions
4a Life/variable life insurance (see instructions)
4a
00
21. Base Premiums (from line 16 at left) ....
21
00
4b Remaining variable life insurance
22. Qualifying health care premiums............
22
00
(attach schedule of all variable life
insurance premiums) ..............................
4b
00
23. Annuity premiums (from line 5 at left).....
23
00
5. Annuity ...................................................
5
00
24. Ocean marine premiums (from line 13)..
24
00
25. Premiums from Utah institutions of
6. Health care .............................................
6
00
higher education (excluding workers’
7. Other disability........................................
7
00
compensation premiums) .......................
25
00
8. Fire including allied lines ........................
8
00
26. Qualifying dividends on life insurance ....
26
00
9. Other than fire including allied lines .......
9
00
27.
....
27
00
Qualifying dividends on fire and allied lines
10. Motor vehicle liability, personal injury
28. Qualifying dividends on premiums other
protection, uninsured motorists ..............
10
00
than life and fire (does not apply to
worker's compensation)..........................
28
00
11. Motor vehicle physical damage
(non-fire portion).....................................
11
00
29. Total deductions (add lines 22 through 28)
29
00
12. Motor vehicle damage (fire portion)........
12
00
30. Net taxable premiums (total base
premiums line 21 less line 29)................
30
00
13. Ocean marine.........................................
13
00
Tax Computation
If amount is less than zero, enter "0."
14. Other (specify): _ __ __ _ _ _ _ _ __
14
00
31. All other workers’ compensation
15. Interest and service charges ..................
15
00
(multiply line 19 by rate – see instructions)
31
00
16. Base Premiums (add lines 4a through 15)
16
00
32. Base premium tax (multiply line 30, less
line 4b, by .0225)...................................
32
00
17. Title insurance ........................................
17
00
Workers’ Compensation
33. Utah variable life (line 4b) times .0008 ...
33
00
18a All agencies ............................................
18a
00
34. Auto insurance value study tax (multiply
line 10 by .0001) .....................................
34
00
18b Deductibles (see instructions) ................
18b
00
19. Total of lines 18a and 18b ......................
19
00
35. Title insurance tax (multiply line 17 by
.0045) .....................................................
35
00
20. Total premiums
(add lines 16, 17 and 19)
Should agree with line 1, 2 or 3 above. ..
20
00
See instructions if amounts do not agree.
Gross Tax Due
36. Tax due on Utah basis (add lines 31 through 35).....................................................................
36
00
37. Tax due on retaliatory basis ................................................ State of Domicile
..
37
00
For retaliatory computation — attach separate page if more space is needed for computation.
DO NOT ENTER ANYTHING BELOW THIS LINE
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