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
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
❿
Individual or firm signature of preparer
Employer Identification number
Address
Date
If you are signing as an authorized delegate of the appropriate corporate officer, check here
and attach Mass. Form M-2848, Power of Attorney.
Mail to: Mass. Department of Revenue, PO Box 7052, Boston, MA 02204. Make check or money order payable to the Commonwealth of Massachusetts.