Statement Of Premiums And Fees For Taxation (To Be Filed On Or Before March 1) Foreign Risk Retention Groups Page 2

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Schedule B – COMPUTATION OF FIRE MARSHAL TAX
(To Be Computed By Property Insurers Only)
PERCENTAGE
* DIRECT
FIRE
TO BE
LINE OF BUSINESS
PREMIUMS
PORTION
APPLIED
Fire Lines
$
100%
$
Farm owners Multiple Peril
55%
$
$
Homeowners Multiple Peril
$
55%
$
Commercial Multiple Peril (non-liability portion & liability portion)
$
50%
$
Inland Marine
20%
$
$
Private Passenger Auto Physical Damage
$
8%
$
Commercial Auto Physical Damage
$
8%
$
Aircraft (All Perils)
8%
$
$
Industrial Fire
$
100%
$
Other
$
$
$
Fire Portion Subject to Fire Marshal Tax (Sum of the above fire portion lines)
0.0075
Apply ¾ of 1%
X
FIRE MARSHAL TAX
$
Do not list negative amounts on any of the above lines; if negative, enter zero (0)
ENTER THIS AMOUNT
ON LINE 6, PAGE 1
* Premiums to agree with respective lines on page 15 (Tennessee business page) from the Annual Statement.
Schedule C– INVESTMENT SCHEDULE
(SEE INSTRUCTION)
Column 1
Column 2
NOTE: Tennessee investments must equal at least 25% of admitted assets before
List name of state in which
Next
Tennessee
company had next highest
Highest
Credit can be allowed.
percentage of admitted
state
assets invested.
1. Real Estate
$
$
2. State, county, municipal, or other political subdivision bonds
$
$
3. Mortgage Loans
$
$
4. Average daily bank balances throughout the current taxable period
$
$
5. Stocks
$
$
6. Any other property or security in which by law such insurance company may invest its funds
$
$
7. Totals
$
$
8. Ratio Column 1 to Column 2
*9. Percentage reduction in Premium Tax
(TENNESSEE INVESTMENTS MUST EQUAL 25% OF TOTAL ADMITTED ASSETS BEFORE ANY CREDITS ARE ALLOWABLE)
10. Premium Tax for Full Calendar Year (Sum of Lines 1, 2, and 8 from page 1)
$
11. Premium Tax As Reported on June 1 and August 20 Only If Investments for First Six Months Period Are not Qualified
($
)
12. Amount of Premium Tax Subject to Reduction (Subtract Line 11 from Line 10)
$
$
13. Tax Reduction for January 1 thru December 31 (Multiply Line 12 by Line 9)
ENTER THIS
AMOUNT ON LINE
10, PAGE 1
Foreign Risk Retention Group Annual Form Rev 12/2009
Page 2 of 5

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