Form 83-391-12-8-1-000 - Mississippi Insurance Company Income Tax Return - 2012 Page 3

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Mississippi
Form 83-391-12-8-3-000 (Rev. 05/12)
MS
Insurance Company Income Tax Return
2012
Page 3
-
FEIN
__ __
__ __ __ __ __ __ __
PART I:
EXPENSE APPORTIONMENT RATIOS
A. Mississippi
B. Company-Wide
C. Mississippi Ratio
Applicable Ratio(s) Used on Page 4, Line 3
1. Loss Adjustment Expenses
__ __ __ . __ __ __ __
%
(Direct Losses)
2. Accident and Health Expenses
__ __ __ . __ __ __ __
(Direct Premiums and Reinsurance Assumed)
%
3. Other Underwriting Expenses
(Direct Premiums (Less Return Premiums), Annuity Considerations and
__ __ __ . __ __ __ __
%
Reinsurance Assumed)
4. Investment Expenses
(Gross Investment Income)
__ __ __ . __ __ __ __
%
PART II:
DEDUCTIONS ALLOCATED
5. Losses, Death Benefits, Accident and Health
Mississippi
Company-Wide
Benefits (Less Applicable Recoveries)
a. Paid
b. Unpaid at December 31st, Current Year
c. Unpaid at December 31st, Prior Year
6. Loss Adjustment Expenses Allocated
7. Matured Endowments
8. Annuity Benefits
9. Disability Benefits
10. Surrender Benefits
11. Payments on Supplementary Contracts
12. Net Additions to Reserve Funds
(Required By Law for Liquidating Policies at Maturity)
13. Commissions
14. Gross Premium Privilege Tax
15. Other Allocable Taxes
16. Rent, Allocated
17. Agency Expense
(Attach Schedule)
18. Medical and Inspection Fees, Allocated
19. Other Allocable Deductions
(Attach Schedule)
PART III:
DEDUCTIONS APPORTIONED
20. Non-Allocable Loss Adjustment Expenses
21. Total Apportioned Expenses
(From Page 4, Part 1, Line 3)
22. Total Allocated and Apportioned Deductions
(Line 20 Plus Line 21; Enter on Page 2, Line 15)

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