Form 74a110 - Kentucky Estimated Insurance Premiums Tax

74A110 (12-04)

WORKSHEET

Page 3

Commonwealth of Kentucky

Estimated Tax for Calendar Year 2005

DEPARTMENT OF REVENUE

Report based on previous year’s liability.

Report based on current year estimate.

A. Taxable premiums on life and health policies ............................................................................................... $

B. Taxable premiums on other than life policies (excluding workers’ compensation policies) ....................... $

C. Total taxable premiums ................................................................................................................................. $

D. 1. Total premiums tax liability for life insurance (multiply line C by 1.5%) ............................................. $

2. Total premiums tax liability for other than life insurance (multiply line C by 2%) ............................... $

E. 1. Prior year credits ...................................................................................................................................... $

2. Guaranty Fund Assessment Credits ......................................................................................................... $

F. Total estimated tax liability (subtract line E from line D) ............................................................................ $

G. Total installment due June 1, 2005 (1/3 of line F) ........................................................................................ $

H. Total installment due October 1, 2005 (1/3 of line F) .................................................................................. $

Projected due March 1, 2006 (1/3 of line F) ................................................................................................. $

DETACH BEFORE MAILING

74A110 (12-04)

FOR OFFICIAL USE ONLY

KENTUCKY ESTIMATED

Commonwealth of Kentucky

DEPARTMENT OF REVENUE

INSURANCE PREMIUMS TAX

3 2

1 0 0 5

__ __

__ __ __ __

Tax

Period

Tr.

Account Number __ __ __ __ __

FEIN __ __ – __ __ __ __ __ __ __

NAIC/

TAX ID

AMENDED SECOND INSTALLMENT

Name of Company

For Calendar Year

Address (Number and Street)

20____

City

State

ZIP Code

(1) Amended

(2) Enter two-thirds

(3) Enter Tax Paid

(4) Amount of Tax

Tax

Estimated Tax

of Estimated Tax

With First Installment

Now Due

Code

A. Premiums tax on life

and health policies ........................

B. Premiums tax on other than life

policies (excluding workers’

compensation policies) .................

C. Retaliatory taxes and fees .............

D. Total of lines A, B and C ..............

I, the undersigned, declare under the penalties of perjury, that I have examined these returns, including all accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct and complete.

Date

Signature of Officer or Agent

Title of Officer

Print or Type Name of Officer or Agent

Telephone Number