Form 207 - Insurance Premiums Tax Return Domestic Companies - 2010
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1Department of Revenue Services
Form 207
2010
State of Connecticut
Insurance Premiums Tax Return
PO Box 2990
Hartford CT 06104-2990
Domestic Companies
(Rev. 12/10)
Complete the return in blue or black ink only.
General Information
D. If this is a fi nal return, is the insurance company:
A.
Check if this is an amended return.
No longer licensed in Connecticut; out of business
B. Change of:
Address
Merged/reorganized _______________________
Domicile, enter new domicile: ___________________
Enter survivor’s CT Tax Registration No.
E. The insurance company is currently in:
C. If this is a short period,
enter period covered by this return: __________________________
Receivership
Rehabilitation
Name of company
Connecticut Tax Registration Number
Taxpayer
Address
Number and street
PO Box
Date received (DRS use only)
Please
type
or print.
(FEIN)
City or town
State
ZIP code
Federal Employer ID Number
1. Gross direct premiums received during the calendar year: See instructions.
1
00
2. Dividends paid: See instructions.
2
00
3. Taxable premiums: Subtract Line 2 from Line 1.
3
00
4. Tax: Multiply Line 3 by 1.75% (.0175).
4
00
5
5. Multiply Line 4 by 70% (.70). See instructions.
00
6 Insurance Department assessment credit: See instructions.
6
00
7. General business tax credits: See instructions.
7
00
8. Add Line 6 and Line 7.
8
00
9. Enter Line 5 or Line 8, whichever is less.
9
00
10. Enter your CIGA assessment credit. See instructions.
10
00
11. Enter your CLHIGA assessment credit. See instructions.
11
00
12. Add Lines 9, 10, and 11.
12
00
13. Net tax: Subtract Line 12 from Line 4. If less than zero, enter zero “0.”
13
00
14. Overpayment applied from prior year
14
00
15. Payments made with estimated tax payment coupons Forms 207 ESA, ESB, ESC, and ESD
15
00
16. Payments made with extension request Form 207/207 HCC EXT
16
00
17. Total prior payments: Add Lines 14, 15, and 16.
17
00
18. If Line 17 is greater than Line 13, enter amount overpaid.
18
00
(19a) $ _____________ refunded
19. Amount to be: credited to 2011 estimated tax
(19b) $ _______________ 19
00
20. If Line 13 is greater than Line 17, enter amount owed.
20
00
(21b) $ _________________ See instructions.
21. If late: penalty
(21a) $ _________________ plus interest
21
00
22. Interest on underpayment of estimated tax: Attach Form 207I. See instructions.
22
00
23. Balance due. Make check payable to Commissioner of Revenue Services.
23
00
Visit the Department of Revenue Services (DRS) website at to pay electronically.
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 DRS is a fi ne of not more than $5,000, 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
Date
Preparer’s SSN or PTIN
for your
records.
Firm name and address
FEIN
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