Form 63-22 - Premium Excise Return For Domestic Insurance Companies

Form 63-22

2001

Premium Excise Return for

Massachusetts

Domestic Insurance Companies

Department of

Revenue

(Except Life 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

Mailing address

DOR use only

Name of treasurer

Check applicable gross investment income tax rate

❿

.01

.008

.006

.004

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 and Underwriting and Investment Exhibit of NAIC Annual Statement.

Income

Use whole dollar method

× .0228 (2.28%) = ❿ 1

11 Taxable premiums (Part I, line 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ $_______________

12 Gross investment income (Part II, line 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ $_______________ × .applicable rate =❿ 2

13 Other (Fair Plan and Crime Prevention disbursement received) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 3

14 Economic Opportunity Area Credit Recapture (attach Schedule H-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 4

15 Excise due before credits.

Add lines 1 through 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Credits

16 Retaliatory surtax credit (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 6

17 Enter 1.5% of company’s total capital contributions in excess of the full proportionate share in investment in the

Massachusetts property and casualty initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 7

18 Credit against premium excise. Add lines 6 and 7. Enter total here, but do not exceed the amount in line 1 . . . . . . . . . . . . . . . 8

19 Enter 10% of Massachusetts Life and Health Insurance Guaranty Association assessment paid previously . . . . . . . . . . . . . ❿ 9

10 Economic Opportunity Area Credit (attach Schedule EOA). If claimed on Form 63-29A, do not claim it here . . . . . . . . . . . ❿ 10

11 Full Employment Credit (attach Schedule FEC). If claimed on Form 63-29A, do not claim it here . . . . . . . . . . . . . . . . . . . . ❿ 11

12 Total credits. Add lines 8 through 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 12

Excise After Credits

13 Excise due before voluntary contribution. Subtract line 12 from line 5. Not less than “0” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

14 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 14

15 Total excise plus voluntary contribution. Add lines 13 and 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 15

Payments

16 2000 overpayment applied to 2001 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 16

17 2001 Massachusetts estimated tax payments (do not include amount from line 15) ❿ 17

18 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 18

19 Total payments. Add lines 16 through 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Refund or Balance Due

20 Amount overpaid. Subtract line 15 from line 19. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

21 Amount overpaid to be credited to 2002 estimated tax. . . . . . . . . . . . . . . . . . . . . . . . ❿ 21

22 Amount overpaid to be refunded. Subtract line 21 from line 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 22

23 Balance due. Subtract line 19 from line 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

24 M-2220 penalty ❿!$_______________________ ; Other penalties ❿ $ ______________________ . . . . . . . . Total penalty 24

25 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 25

26 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 26

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

Individual or firm signature of preparer

Employer Identification number

Address

Date

❿

If you are signing as an authorized delegate of the appropriate corporate officer, check here