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.
Question | Answer |
---|---|
Form Name | Form Rct 121 C |
Form Length | 3 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 45 sec |
Other names | prepayments, 2011, E-mail, NAIC |
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 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
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 |
ANNUAL PAYMENTS
TAX YEAR ENDING
12/31/11
DUE DATE
04/15/12
|
REVENUEUSEONLY |
A.TaxLiability |
B.Estimated |
C.Restricted |
Remittance |
||
TAXTYPE |
Payments&Credits |
||||||
TYPE |
BUDGET |
fromTaxReport |
Credit |
AminusBminusC |
|||
|
onDeposit |
||||||
|
CODE |
CODE |
|
|
|
||
|
|
|
|
|
|||
60 |
710101 |
|
|
|
|
||
|
|
|
|
|
|
|
|
60 |
125163 |
|
|
|
|
||
|
|
|
|
|
|
|
|
60 |
115101 |
|
|
|
|
||
|
|
|
|
|
|
|
|
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 |
|
|
|
|
|
|
|
|
|
|
|
1213011101 |
1213011101 |
1213011201
RETALIATORY WORKSHEET
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 |
|
|
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.
(wholedollarsonly)
16.
(wholedollarsonly)
17. Total(Line15plusLine16)ForeignCasualtyorFire;EnterthisamountonPage1,ColumnA ............................
(wholedollarsonly)
Á
Á
Á
1213011301