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2001

Form 63-23

Premium Excise Return

Massachusetts

Department of

for All Classes of Foreign Insurance Companies

Revenue

(Except Life Insurance Companies and Companies with Respect to Ocean Marine Business)

For calendar year 2001 or taxable year beginning

2001 and ending

Name of company

Federal Identification number

❿

Mailing address

DOR use only

Name of treasurer

Organized under the laws of

Has the federal government changed your taxable income for any prior year which has not yet been reported to Massachusetts?

Yes

No.

Computation of Excise.

Attach a copy of Schedule T of NAIC Annual Statement.

Income and Deduction

Use whole dollar method

❿ 1

11 Total net direct premiums for insurance of property or interests in Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12 Other (Fair Plan and Crime Prevention Premiums) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 2

13 Total income. Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

14 Dividend deduction. Premiums returned or credited to policyholders as dividends (unabsorbed premium deposits)

on direct business. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 4

Excise

15 Amount taxable. Subtract line 4 from line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

16 Tax at 2.28% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 6

17 Tax computed under retaliatory provisions (enter full amount). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 7

18 Economic Opportunity Area Credit Recapture (attach Schedule H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 8

19 Applicable excise before credits. Enter the larger of line 6 plus line 8 or line 7 plus line 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Credits

10 Enter 1.5% of company’s capital contribution in excess of your full proportionate share in the Massachusetts Property

and Casualty initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 10

11 Enter 10% of Mass. and Health Insurance Guaranty Association assessment paid in the prior years (see instructions) . . . ❿ 11

❿ 12

12 Economic Opportunity Area Credit (attach Sch. EOA). If credit was claimed on Form 63-29A, do not claim it on this form

13 Full Employment Credit (attach Schedule FEC). If this credit was claimed on Form 63-29A, do not claim it on this form. . . ❿ 13

Excise After Credits

14 Excise due before voluntary contribution. Subtract the total of lines 10 through 13 from line 9. Not less than “0”. . . . . . . . . . . 14

15 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 15

16 Total excise plus voluntary contribution. Add lines 14 and 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 16

Payments

17 2000 overpayment applied to 2001 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 17

18 2001 estimated tax payments (do not include amount from line 17). . . . . . . . . . . . . . ❿ 18

19 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 19

20 Total payments. Add lines 17 through 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Refund or Balance Due

21 Amount overpaid. Subtract line 16 from line 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

22 Amount overpaid to be credited to 2002 estimated tax. . . . . . . . . . . . . . . . . . . . . . . . ❿ 22

23 Amount overpaid to be refunded. Subtract line 22 from line 21. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 23

24 Balance due. Subtract line 20 from line 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

25 M-2220 penalty ❿$ _______________________ ; Other penalties ❿$ ______________________ . . . . . . . . Total penalty 25

26 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 26

27 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 27

28 Are net direct premiums so reported in line 1?

Yes

No. Have all dividends claimed as a deduction in line 4 been

included as taxable premiums in line 1 on this return or on a previous Massachusetts return?

Yes

No.

Under the penalties of perjury, I declare that I have examined this return, including attachments, and to the best of my knowledge and belief, it is

true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which he/she has knowledge.

Signature of appropriate corporate officer (see instructions)

Social Security number

Telephone number

Date