Form 207f - Insurance Premiums Tax Return Nonresident And Foreign Companies

2004

Department of Revenue Services

Form 207F

State of Connecticut

PO Box 2990

Insurance Premiums Tax Return

Hartford CT 06104-2990

Nonresident and Foreign Companies

(Rev. 12/04)

Purpose: Each nonresident or foreign 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:

•

CT Insurance Premiums Tax Registration No.

A copy of Schedule T;

•

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

•

2004 Schedule GAA, if applicable;

Date Received (For Department Use Only)

•

2004 Form 207I, if applicable.

Federal Employer Identification Number

Please

make

changes to

Organized Under the Laws of

your name

and

address if

shown

Check if this is a new address

incorrectly

Check if this is an amended return

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

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

Net direct premiums received during the year from ocean marine insurance policies written on property located in

this state

Benefit payments from group health insurance premiums to the extent allowed by Conn. Gen. Stat. §12-210a

Total deductions (Add Lines 2, 3, and 4)

Taxable premiums (Subtract Line 5 from Line 1)

Multiply Line 6 by 1.75% (.0175)

Taxes and other obligations on retaliatory basis (See instructions on back)

Other obligations paid to Connecticut (See instructions on back)

Retaliatory computations (Subtract Line 9 from Line 8)

Tax (Enter Line 7 or Line 10 amount, whichever is greater)

Assessment credits: (12a) CIGA $ _________________________ (12b) CLHIGA $ ________________________

13a General business tax credits (See instructions on back)

13a

13b Multiply Line 11 by 70% (.70) (See instructions on back)

13b

13c Enter Line 13a or Line 13b, whichever is less

13c

Total credits (Add Line 12 and Line 13c)

Subtract Line 14 from Line 11 (If less than zero, enter zero (0))

Overpayment applied from prior year

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

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

Total prior payments (Add Lines 16, 17, and 18)

If Line 19 is greater than Line 15, enter amount overpaid

(21a) $_________________ Refunded

Amount to be: Credited to 2005 estimated tax

(21b) $________________ 21

If Line 15 is greater than Line 19, enter amount owed

If late: penalty (23a) $______________________ plus interest (23b) $__________________(See instructions)

Interest on underpayment of estimated tax (Attach Form 207

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.

Signature of Principal Officer

Title

Date

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Keep a copy

Print Name of Principal Officer

Telephone Number

of this return

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)

for your