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

Part I. Premium Excise

11 Total of all net direct premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨ 1

12 Net direct premiums for insurance of property or interests in other states or countries where a

tax is actually paid by said company or its agents (Supporting schedule is required showing by states . . . . . . . . . . . . . . . . ¨ 2

the total business written. Copy of Schedule T is accepted, if admitted states are designated.)

States or countries in

Massachusetts

which company pays no tax

Total

add A + B

13 Total net direct premiums subject to tax

Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . 3a ¨ $

¨ $

14 Premiums returned or credited to policyholders

as dividends (unabsorbed premium

¨ $

deposits) on direct premiums. . . . . . . . . . . . . . . . . 4a

15 Taxable premiums. Subtract line 4 from

line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a $

Enter line 5 in line 1 in Computation of Excise.

Part II. Gross Investment Income

From NAIC Annual Statement, Form 2, Underwriting and Investment Exhibit, Part I, Column 8, or Form 9, Operations and Investment Exhibit, Part I, Column 8,

for the taxable year.

11 Interest on bonds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

12 Dividends on preferred stocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

13 Dividends on common stocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

14 Interest on mortgage loans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

15 Real estate income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

16 Interest on collateral loans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

17 Cash on deposit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

18 Other invested assets

a __________________________________________________________________ 8a

b __________________________________________________________________ 8b

c __________________________________________________________________ 8c

d __________________________________________________________________ 8d

e __________________________________________________________________ 8e

19 Total invested assets. Add lines 8a through 8e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

10 Gross investment income. Add lines 1 through 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Enter line 10 in line 2 in Computation of Excise

Form 63-22

printed on recycled paper