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RCT-124 (11-11) (I)

1240011101

MARINE INSURANCE TAX REPORT

DOMESTIC AND FOREIGN MARINE INSURANCE

Bureau of Corporation Taxes

2011 REPORT

PO BOX 280407

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

o First Report

o Amended Report (See instructions.)

o LastReport (See instructions.)

ANNUAL PAYMENTS

TAX YEAR ENDING

DUE DATE

06/01/12

12/31/11

Fillincorrespondingself-assessedtax,prepayments,restrictedcredit,remittanceamountandgrandtotals.

REVENUEUSEONLY

A.TaxLiability

B.Estimated

C.Restricted

Remittance

TAX TYPE

Payments&Credits

TYPE

BUDGET

fromTaxReport

Credit

AminusBminusC

onDeposit

CODE

DOMESTICMARINE

125161

FOREIGNMARINE

125164

GRAND TOTALS

oPLEASE CHECK THIS BLOCK 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 = Automatically transfer overpayments to other underpaid taxesfor the current tax period, then to the next tax period. B = Refund overpayment(s) of the current tax period after paying any other underpaid taxes for the current tax period.

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

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

Signature of Officer			Title	Date	Telephone Number
					(	)

Iaffirmunderpenaltiesprescribedbylaw,thisreport(includinganyaccompanyingschedulesandstatements)hasbeenpreparedbymeandtothebestofmyknowledgeandbeliefisa
true,correctandcompletereport.

PRINTIndividual Preparer or Firm’s Name			Signatureof Preparer		Fax Number
					(	)

PRINTIndividual or Firm’s Street Address			Title		Telephone Number
					(	)

City	State	ZIP Code	E-mail Address

1240011101

1240011201

SCHEDULE A

MARINE PREMIUMS WRITTEN WITHIN THE U.S.

RCT-124(I)

Page 2

(Excludingpremiumsonbusinessfallingwithintheprovisionsof72P.S.§2281(c)imposingastatetaxonmarineinsuranceunderwritingprofits.)

ITEMS	1	2	3	4	5	6
						NETPREMIUMSLESS
	LAST THREE	GROSS	RETURN	NET	NET

						NETREINSURANCE
	CALENDAR YEARS	PREMIUMS	PREMIUMS	PREMIUMS	REINSURANCE
						PREMIUMS

aYear 2009 b Year 2010 c Year 2011 d Totals

SCHEDULE B

MARINE PREMIUMS WRITTEN WITHIN THE COMMONWEALTH OF PENNSYLVANIA

ITEMS	1	2	3	4	5	6
	1	2	3	4	5	NETPREMIUMSLESS
	LAST THREE	GROSS	RETURN	NET	NET

						NETREINSURANCE
	CALENDAR YEARS	PREMIUMS	PREMIUMS	PREMIUMS	REINSURANCE	NETREINSURANCE
	CALENDAR YEARS	PREMIUMS	PREMIUMS	PREMIUMS	REINSURANCE	PREMIUMS
						PREMIUMS

a	Year 2009

b	Year 2010

c	Year 2011

dTotals

SCHEDULE C

PREMIUMS WRITTEN – ALL CLASSES OF BUSINESS – FOR THE LAST THREE CALENDAR YEARS

WITHIN THE U.S.

ITEMS	1	2	3	4	5	6
	1	2	3	4	5	NETPREMIUMSLESS
	LAST THREE	GROSS	RETURN	NET	NET	NETPREMIUMSLESS
	LAST THREE	GROSS	RETURN	NET	NET	NETREINSURANCE
	CALENDAR YEARS	PREMIUMS	PREMIUMS	PREMIUMS	REINSURANCE	NETREINSURANCE
						PREMIUMS



a	Year 2009

b	Year 2010

c	Year 2011

dTotals

SCHEDULE D

UNEARNED PREMIUMS ON OUTSTANDING MARINE INSURANCE CONTRACTS (WRITTEN WITHIN THE U.S.)

AT CLOSE OF BUSINESS DEC. 31 FOR LAST FOUR CALENDAR YEARS.

		TRIP(OrVoyage)CONTRACTS		TERMCONTRACTS		ADVANCE
	1	TRIP(OrVoyage)CONTRACTS		TERMCONTRACTS		PREMIUMS	7
	1					PREMIUMS	7
ITEMS	LAST FOUR	2	3	4	5	6	TOTAL NET
	CALENDAR YEARS	PREMIUMS IN	NET UNEARNED	PREMIUMS IN	NET UNEARNED	NET UNEARNED	UNEARNED
		FORCE LESS	PREMIUMS	FORCE LESS	PREMIUMS 50%	PREMIUMS	PREMIUMS
		FORCE LESS	PREMIUMS	FORCE LESS	PREMIUMS 50%	PREMIUMS	PREMIUMS
		REINSURANCE	100%	REINSURANCE		100%

a	Year 2008

b	Year 2009

c	Year 2010

dYear 2011

1240011201

	RCT-124(I)
1240011301	Page 3
1240011301

SCHEDULE E

MARINE LOSSES INCURRED ON BUSINESS WRITTEN WITHIN THE U.S.

FOR LAST THREE CALENDAR YEARS

ITEMS	1	2	3	4	5	6
	LAST THREE	GROSS	REINSURANCE	SALVAGE	TOTAL	NET
	LAST THREE	GROSS			TOTAL	(Column 2 minus
	CALENDAR YEARS	LOSSES			(Columns 3 and 4)	(Column 2 minus
						Column 5)
a	Year 2009

b	Year 2010

c	Year 2011

dTotals

SCHEDULE F

SPECIFIC MARINE EXPENSES INCURRED ON BUSINESS TRANSACTED WITHIN THE U.S.

	1	2	3	4	5	6	7	8
ITEMS	LAST THREE	AGENCY	AGENCY	FEDERAL	STATE & CITY	LOSS	ALLOTHER	TOTAL
ITEMS	CALENDAR	COMMISSIONS	EXPENSES	TAXES	TAXES & FEES	ADJUSTMENT	EXPENSES	COLUMNS2-7
	YEARS	INCLUDING				EXPENSE
	YEARS	BROKERAGE				EXPENSE

a	Year 2009

b	Year 2010

c	Year 2011

dTotals

SCHEDULE G

GENERAL EXPENSES NOT CHARGEABLE SPECIFICALLY TO ANY PARTICULAR CLASS OF BUSINESS

	1	2	3	4	5	6	7	8
ITEMS	LAST THREE	SALARIES OF	ADVERTISING	FEDERAL	RENTS	PRINTING &	ALLOTHER	TOTAL
ITEMS	CALENDAR	OFFICERS &	&	TAXES	RENTS	STATIONERY	EXPENSES	COLUMNS2-7
	YEARS	EMPLOYEES	SUBSCRIP-
	YEARS	EMPLOYEES	TIONS

a	Year 2009

b	Year 2010

c	Year 2011

dTotals


e.	Three-year ratio of U.S. marine premiums (Schedule A, Column 4, Item d) to total net premiums for all classes
e.	of business within the U.S. (Schedule C, Column 4, Item d)	%
f.	Three-year ratio of net marine premiums written within Pennsylvania (Schedule B, Column 4, Item d)
f.	to total net marine premiums written within the U.S. (Schedule A, Column 4, Item d)	%
	Attach Copy of Pennsylvania Business Page of the Annual Report filed with the Pennsylvania Insurance Department.
	NOTE: If the company is licensed to write ocean marine premiums in Pennsylvania, this report must be filed whether or not ocean
	marine premiums were written.

1240011301

	RCT-124 (I)
1240011401	Page 4

TOTAL UNDERWRITING PROFIT ON MARINE BUSINESS TRANSACTED WITHIN THE U.S.

1.	Net Premiums, less Net Reinsurance Premiums, written within the U.S.
	(Schedule A, Column 6, Item d)	.$
2.	Plus: Net Unearned Marine Premiums on U.S. business at beginning of
	four-year period (Schedule D, Column 7, Item a)	.$
3.	Total (Line 1 plus Line 2)	.$
4.	Less: Net Unearned Marine Premiums on U.S. business at end offour-
	year period (Schedule D, Column 7, Item d)	.$
5.	Net Marine Premiums Earned (Line 3 minus Line 4)	.$
6.	Net Marine Losses incurred on business written within the U.S.
	(Schedule E, Column 6, Item d)	.$
7.	Specific Marine Expenses incurred (Schedule F, Column 8, Item d)	.$
8.	Proportion of general expenses chargeable to U.S. Marine Premiums
	(Schedule G, Item e multiplied by Schedule G, Column 8, Item d)	.$
9.	Total Deductions (Line 6 plus Line 7 plus Line 8)	.$
10.	Net Marine Underwriting Profit on business written within the U.S.
	(Line 5 minus Line 9)	.$
11.	Net Marine Underwriting Profit on business written within Pennsylvania
	for three years (Line 10 multiplied by Schedule G, Item f)	.$
12.	Average Net Marine Underwriting Profit on business within Pennsylvania
	for one year (0.33 x Line 11)	.$
13.	Tax at 5 percent on Average Net Marine Underwriting Profit on business within Pennsylvania for one
	year (0.05 x Line 12) Enter this amount on Page 1, ColumnA (whole dollars only)	.$

IF ALIEN, GIVE NAME OF STATE IN WHICH PRINCIPAL U.S. OFFICE IS LOCATED

DATE BUSINESS COMMENCED IN PENNSYLVANIA

INCORPORATED OR ORGANIZED UNDER THE LAWS OF:

THIS REPORT IS MADE BY A STOCK COMPANY, ASSOCIATION, EXCHANGE, ETC. (PLEASE SPECIFY)

1240011401

Question	Answer
Form Name	Rct 124 Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	CHARGEABLE, 2009, rct 124, prepayments

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