Form 207f - Insurance Premiums Tax Return Nonresident And Foreign Companies

Department of Revenue Services

2008

Form 207F

State of Connecticut

PO Box 2990

Insurance Premiums Tax Return

Hartford CT 06104-2990

Nonresident and Foreign Companies

(Rev. 12/08)

Complete this return in blue or black ink only.

General Information:

A. Return Status:

Amended

D. If this is a ﬁ nal return, is the insurance company:

No longer licensed in Connecticut; out of business

B. Change of:

Address

Merged/Reorganized

Domicile, Enter new domicile:

Enter survivor’s Connecticut Tax Registration Number.

C. If this is a short period,

E. The insurance company

enter period covered by this return:

is currently in:

Receivership

Rehabilitation

Name of Company

Connecticut Tax Registration Number

Taxpayer

Date Received (DRS Use Only)

Address

Number and Street

PO Box

Type

Federal Employer ID Number (FEIN)

City, or Town

State

ZIP Code

Organized Under the Laws of

Enter gross direct premiums received during the calendar year. See instructions.

Dividends paid: See instructions.

Net direct premiums received during the year from ocean marine insurance policies written on property

located in this state

Beneﬁ t payments from group health insurance premiums to the extent allowed by Conn. Gen. Stat. §12-210a

Total deductions: Add Lines 2, 3, and 4.

Taxable premiums: Subtract Line 5 from Line 1.

Multiply Line 6 by 1.75% (.0175).

Taxes and other obligations on retaliatory basis: See instructions.

Other obligations paid to Connecticut: See instructions.

Retaliatory computation: Subtract Line 9 from Line 8.

Tax: Enter Line 7 or Line 10 amount, whichever is greater.

Multiply Line 11 by 70% (.70). See instructions.

General business tax credits: See instructions.

Enter Line 12 or Line 13, whichever is less.

Enter CIGA assessment credit. See instructions.

Enter CLHIGA assessment credit. See instructions.

Total credits: Add Lines 14, 15, and 16.

Net tax: Subtract Line 17 from Line 11. If less than zero, enter “0.”

Overpayment applied from prior year

Payments made with estimated tax payment coupons from Forms 207F ESA, ESB, ESC, and ESD

Payments made with extension request from Form 207F EXT

Total prior payments: Add Lines 19, 20, and 21.

If Line 22 is greater than Line 18, enter amount overpaid.

(24a) $ _____________ Refunded

Amount to be credited to 2009 estimated tax

(24b) $ ______________ 24

If Line 18 is greater than Line 22, enter amount owed.

If late: penalty (26a) $ _______________ plus interest (26b) $ ________________ See instructions.

Interest on underpayment of estimated tax: Attach Form 207I. See Instructions.

Balance due with this return

Make check payable to: Commissioner of Revenue Services.

Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) and, to the best of my knowledge

and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or document to the Department of Revenue Services (DRS)

is a ﬁ ne of not more than $5,000, or imprisonment for not more than ﬁ ve years, or both. The declaration of a paid preparer other than the taxpayer is based on all

information of which the preparer has any knowledge.

Signature of Principal Ofﬁ cer

Title

Date

Sign Here

Print Name of Principal Ofﬁ cer

Telephone Number

Keep a copy

(

)

of this return

Paid Preparer’s Signature