Part I. Premium Excise
Life Premiums
Income
11 All new and renewal direct premiums for all policies of life insurance allocable to Massachusetts . . . . . . . . . . . . . . . . . . . . . ¨ 1
$
12 Dividends applied to:
a Purchase paid-up additions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨ 2a
$
b Shorten premium paying period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨ 2b
$
13 Total gross direct premiums. Add lines 1, 2a and 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
$
Deductions
14 Returned premiums but not including cash surrender values. . . . . . . . . . . . . . . . . . . . ¨ 4
$
(Itemized supporting schedule is required as part of line 4)
15 Dividends:
a Paid in cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨ 5a
$
b Applied in reduction of renewal premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨ 5b
$
c Left to accumulate at interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨ 5c
$
d Applied to purchase paid-up additions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨ 5d
$
e Applied to shorten premium paying period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨ 5e
$
16 Total deductions. Add lines 4 through 5e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
$
Taxable amount
17 Taxable amount. Subtract line 6 from line 3
(Enter line 7 in line 1 in Computation of Excise) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
$
Accident and Health Premiums
Income
18 Total net direct premiums for insurance of property or interests in Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨ 8
$
Deductions
19 Dividend deduction. Premiums returned or credited to policyholders as dividends
(unabsorbed premium deposits) on direct business . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨ 9
$
10 Premium deduction. Gross premiums for authorized Preferred Provider arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . ¨ 10
$
11 Total deductions. Add line 9 and line 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
$
Taxable amount
12 Taxable amount. Subtract line 11 from line 8
(Enter line 12 in line 4 in Computation of Excise) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
$
Part II. Computation of Retaliatory Tax
Use the space below to calculate your excise using the identical method and the same rate used by the state in which you are incorporated in taxing a like
Massachusetts insurance company, or its agents, if doing business to the same extent. If the computation in the state of your incorporation is in every respect
the same as your Massachusetts computation, a statement to that effect should be made.
Column A. Life computation
Column B. Accident and health computation