SCHEDULE 1
INDUSTRIAL INSURANCE PREMIUM TAX AND FEES ON RETALIATORY BASIS
(WORKERS COMPENSATION)
FOR YEAR ENDING DECEMBER 31, 2010
(A)
(B)
NEVADA BASIS
STATE OF INC
1. Gross Annual Premiums (Industrial Insurance Only)
1.
2. Dividends Paid or Credited to Policy Holders
2.
3. Gross Premiums written minus Dividends paid or Credited to Policy Holders
3.
4. Taxes Payable (according to applicable rate) (Tax Rate for Nevada is 3.5%)
4.
Must agree with Line 7, IIP-R on Annual Reconciliation Return
5. Retaliatory Assessment
5.
IIP-R
Revised 12-21-10