Part I. Premium Excise
11 Total of all net direct premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 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 . . . . . . . . . . . . . . . . ❿ 2
the total business written. Copy of Schedule T is accepted, if admitted states are designated.)
b.
a.
States or countries in
Total
Massachusetts
which company pays no tax
add a + b
13 Total net direct premiums subject to tax
❿ $
❿ $
Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . 3a
3b
3
14 Premiums returned or credited to policyholders
as dividends (unabsorbed premium
❿
deposits) on direct premiums. . . . . . . . . . . . . . . . . 4a
15 Taxable premiums. Subtract line 4 from
line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a
$
5b
$
5
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