Form Rct 121 C PDF Details

In order to ensure you are providing the best possible care for your patients, it is important to be familiar with all of the available resources. Form Rct 121 C is a valuable resource that can help you improve patient care. This form allows you to document a patient's response to a medication and helps to track any side effects they may experience. Knowing how to use this form can help you provide better care for your patients.

QuestionAnswer
Form NameForm Rct 121 C
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesprepayments, 2011, E-mail, NAIC

Form Preview Example

RCT-121-C (11-11) (I)

1213011101

 

 

 

 

GROSS PREMIUM TAX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR FOREIGN CASUALTY OR FOREIGN FIRE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bureau of Corporation Taxes

INSURANCE COMPANIES, ASSOCIATIONS OR EXCHANGES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PO BOX 280407

 

2011 REPORT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Harrisburg PA 17128-0407

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CORP TAX ACCOUNT ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(DepartmentUseOnly)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DateReceived

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEDERAL ID (EIN)

 

 

 

 

 

 

 

 

 

_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o Check to send all correspondence to preparer.

 

 

 

 

 

o Check to indicate a change of address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State of Domicile

 

 

 

 

 

 

 

NAIC No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o First Report o Amended Report (See instructions.)

o EIP Credit o LastReport (Out-of-Existence as of ___________________.)

ANNUAL PAYMENTS

TAX YEAR ENDING

12/31/11

DUE DATE

04/15/12

Fillincorrespondingself-assessedtax,prepayments,restrictedcredit,remittanceamountandgrandtotals.

 

REVENUEUSEONLY

A.TaxLiability

B.Estimated

C.Restricted

Remittance

TAXTYPE

Payments&Credits

TYPE

BUDGET

fromTaxReport

Credit

AminusBminusC

 

onDeposit

 

CODE

CODE

 

 

 

 

 

 

 

 

FOREIGNCASUALTY-2%

60

710101

 

 

 

 

 

 

 

 

 

 

 

FOREIGNCASUALTY-RETALIATORY

60

125163

 

 

 

 

 

 

 

 

 

 

 

FOREIGNFIRE-2%

60

115101

 

 

 

 

 

 

 

 

 

 

 

FOREIGNFIRE-RETALIATORY

60

125165

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GRAND TOTALS

oPLEASE CHECK THIS BOX ONLY IF THE TOTAL PAYMENT SHOWN ABOVE HAS BEEN OR WILL BE PAID ELECTRONICALLY.

OVERPAYMENT INSTRUCTIONS (Choose only Option A or Option B and write the appropriate letter in the box provided.)

oA=Automaticallytransferoverpaymentstootherunderpaidtaxesforthecurrenttaxperiod,thentothenexttaxperiod. B=Refundoverpayment(s)ofthecurrenttaxperiodafterpayinganyotherunderpaidtaxesforthecurrenttaxperiod.

Bycheckingthe“AmendedReport”boxonthisform,thetaxpayerconsentstotheextensionoftheassessmentperiodforthistaxyeartooneyearfromthedateoffilingofthisamendedreport orthreeyearsfromthefilingoftheoriginalreport,whicheverperiodlastexpires.Forpurposesofthisextension,anoriginalreportfiledbeforetheduedateisdeemedfiledontheduedate.

Iaffirmunderpenaltiesprescribedbylawthatthisreport(includinganyaccompanyingschedulesandstatements)wasexaminedbyme,tothebestofmyknowledgeandbeliefisatrue,cor- rectandcompletereportandIamauthorizedtoexecutethisconsenttotheextensionoftheassessmentperiod.ThisdeclarationisbasedonallinformationofwhichIhaveanyknowledge.

SignatureofOfficer

 

 

Title

Date

TelephoneNumber

 

 

 

 

 

(

)

 

 

 

 

Iaffirmunderpenaltiesprescribedbylaw,thisreport(includinganyaccompanyingschedulesandstatements)hasbeenpreparedbymeandtothebestofmyknowledgeandbeliefisa

true,correctandcompletereport.

 

 

 

 

 

 

 

 

 

 

 

 

PRINTIndividualPreparerorFirm’sName

 

 

SignatureofPreparer

 

FaxNumber

 

 

 

 

 

(

)

 

 

 

 

 

 

PRINTIndividualorFirm’sStreetAddress

 

 

Title

 

TelephoneNumber

 

 

 

 

 

(

)

 

 

 

 

 

 

 

City

State

ZIPCode

E-mailAddress

 

 

 

 

 

 

 

 

 

 

1213011101

1213011101

1213011201

RETALIATORY WORKSHEET

RCT-121-C (I) Page 2

SCHEDULEOFTAXES,ASSESSMENTS,LICENSESANDFEES

 

 

PENNSYLVANIA

STATEOFDOMICILE

PremiumTaxes:

 

 

$

$

Fire,CasualtyandTitlePremiums

 

 

OceanMarineGrossProfitTax

 

 

LifePremiums

 

 

Annuities

 

 

AccidentandHealthPremiums

 

 

ReinsuranceAssumedfromUnauthorizedCompanies

 

 

 

 

 

OtherTaxes(FireMarshal,Franchise,Income,etc.)

 

 

Worker’sCompensationAssessments(NotaretaliatoryitemforPA)

OtherAssessments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LicensesandFees(AnnualBasis)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Totals

$

$

 

 

RetaliatoryPayabletothePADepartmentofRevenue

 

$

.............................

 

ANSWER THE FOLLOWING QUESTIONS

(a)How many agents are licensed to represent your company in Pennsylvania during the tax year?

(b)What are your state fees for licensing agents of similar Pennsylvania insurers?

(c) Are the fees in Question (b) imposed on the company

 

or the agent?

1213011201

1213011301

RCT-121-C (I)

 

Page 3

ATTACHCOPYOFPENNSYLVANIABUSINESSPAGEANDSCHEDULETOFTHEANNUALREPORTFILEDWITHTHEPENNSYLVANIAINSURANCEDEPARTMENT.

Fire, Casualty and Title Insurers (Do not include Ocean Marine Premiums.)

1. GrossDirectPremiumsReceivedLessCancellationsandPremiumsReturned ........................................ $

2. Less:ExtraordinaryMedicalBenefitPremiums ..............................................................

3. Less:DividendstoPolicyholders ........................................................................

4. Less:OtherDeductions(Attachschedule.) ................................................................

5. PremiumsTaxable(Line1minusLines2,3and4) ..........................................................

LifeInsurers

6. GrossLifePremiums(DirectWritingBasis) ........................................... $

7. Less:DividendstoPolicyholders ...................................................

8. Less:OtherDeductions(Attachschedule.) ...........................................

9. LifePremiumsTaxable(Line6minusLines7and8) .........................................................

AccidentandHealthInsurers

10. GrossDirectAccidentandHealthPremiums .......................................... $

11. Less:DividendstoPolicyholders ...................................................

12. Less:OtherDeductions(Attachschedule.) ...........................................

13. AccidentandHealthPremiumsTaxable(Line10minusLines11and12) ...........................................

14. TotalTaxablePremiums(AddLines5,9and13) ............................................................

15. Tax(Line14times0.02)ForeignCasualtyorFire-2percent;EnterthisamountonPage1,ColumnA......................

(wholedollarsonly)

16. Retaliatory(FromPage2ofReport)ForeignCasualtyorFire-Retaliatory;EnterthisamountonPage1,ColumnA .............

(wholedollarsonly)

17. Total(Line15plusLine16)ForeignCasualtyorFire;EnterthisamountonPage1,ColumnA ............................

(wholedollarsonly)

Á

Á

Á

1213011301