Form 207 - Insurance Premiums Tax Return Domestic Companies

2004

Department of Revenue Services

Form 207

State of Connecticut

PO Box 2990

Insurance Premiums Tax Return

Hartford CT 06104-2990

Domestic Companies

(Rev. 12/04)

Purpose: Each domestic insurance company authorized to conduct insurance business in Connecticut must file this return on or before

March 1, 2005, to report its insurance premiums tax liability for calendar year 2004.

Attach the following to this return:

•

A copy of Schedule T;

•

Connecticut business page from the Annual Statement filed with the Insurance Department;

•

2004 Schedule GAA, if applicable;

•

2004 Form 207I, if applicable.

CT Insurance Premiums Tax Registration No.

Please

make

Date Received (For Department Use Only)

changes to

your name

and

address if

Federal Employer Identification Number

shown

incorrectly

Check if this is a new address

Check if this is an amended return

1 Gross direct premiums (less return premiums, including cancellations) received during the calendar year from

policies written on property or risks located or resident in this state, excluding annuity considerations and premiums

received for reinsurance assumed from other companies

2 Dividends paid to policyholders on direct business, not including dividends paid on account of the ownership of stock

3 Taxable premiums (Subtract Line 2 from Line 1)

4 Tax: Multiply Line 3 by 1.75% (.0175)

5 Assessment credits: (5a) CIGA $ ___________________________ (5b) CLHIGA $ _________________________

6 Insurance Department assessment credit (See instructions on back)

7 General business tax credits (See instructions on back)

8a Add Line 6 and Line 7

8b Multiply Line 4 by 70% (.70) (See instructions on back)

8c Enter Line 8a or Line 8b, whichever is less

9 Add Line 5 and Line 8c

10 Subtract Line 9 from Line 4 (If less than zero, enter zero (0))

11 Overpayment applied from prior year

12 Payments made with estimated tax payment coupons (Forms 207 ESA, ESB, ESC, and ESD)

13 Payments made with extension request (Form 207/207F EXT) (See instructions on back)

14 Total prior payments (Add Lines 11, 12, and 13)

15 If Line 14 is greater than Line 10, enter amount overpaid

(16a) $_________________ Refunded

16 Amount to be: Credited to 2005 estimated tax

(16b) $__________________ 16

17 If Line 10 is greater than Line 14, enter amount owed

18 If late: penalty (18a) $ ___________________ plus interest

(18b) $ ___________________ (See instructions)

19 Interest on underpayment of estimated tax (Attach Form 207I) (See instructions on back)

20 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 to DRS is a fine of not more than $5,000,

or imprisonment for not more than five 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.

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