Form 207 - Insurance Premiums Tax Return Domestic Companies

Department of Revenue Services

Form 207

State of Connecticut

2001

PO Box 2990

Hartford CT 06104-2990

Insurance Premiums Tax Return

Domestic Companies

(Rev. 12/01)

Purpose - Each domestic insurance company authorized to do an insurance business in Connecticut must file this return on or

before March 1, 2002, to report its insurance premiums tax liability for calendar year 2001.

A copy of Schedule T and the Connecticut business page from the Annual Statement filed with the Insurance Department

must accompany this return.

CT Insurance Premiums Tax Registration No.

Date Received (For Department Use Only)

Federal Employer Identification Number

Check if this is an amended return

1 Gross direct premiums ( less returned 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 2

3 Taxable premiums (Subtract Line 2 from Line 1)

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

5 Insurance Department Assessment Credit (80% of the assessment paid under Conn. Gen. Stat. §38a-48 during

the calendar year by a qualifying local domestic insurance company) (See instructions on reverse side)

6 CIGA and CLHIGA assessment credits (Attach Schedule GAA)

7 Other Connecticut business tax credits (See instructions on reverse side)

8 Total credits (Add Lines 5, 6, and 7)

9 Subtract Line 8 from Line 4. (If less than zero, enter zero)

Overpayment applied from prior year

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

Payments made with extension request (Form 207/207F EXT)

Total prior payments (Add Lines 10, 11, and 12)

Balance of tax due (overpaid) (Subtract Line 13 from Line 9)

If late: penalty (15a) $ ___________________ plus interest (15b) $ ___________________ ( See instructions ) =

Interest on underpayment of estimated tax ( Attach Form 207 I)

17 Amount to be credited to 2002 estimated tax (17a) $ ______________ refunded (17b) $ ______________ =

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 that 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.

Signature of Principal Officer

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Print Name of Principal Officer

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