Form IIP-R Fillable Annual Insurance Premium Tax Return (Not for reporting Industrial Insurance)
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

A Total Overpayments applied from previous years All inclusive basis Amount to be refunded Amount: B Total Overpayments refunded by Nevada in 2010 Back End: Date Election Approved by Commissioner: Check No: DO NOT INCLUDE INDUSTRIAL INSURANCE (WORKERS COMPENSATION) Federal ID: If line 10 results in an overpayment the overpayment may be applied to next years taxes or the overpayment may be Initials: Premium Tax: Retaliatory Tax: Risk rate See page 10 for line by line instructions See page 11 for line by line instructions See page 12 for line by line instructions See page 13 for line by line instructions See page 8 for line by line instructions See page 9 for line by line instructions Total Remittance: (A) Nevada Basis (B) State of Domicile (zero) here no Retaliatory Assessment is owed 1 Accident and Health Premiums 1 Direct Life Insurance Premiums Written 1 Direct Premiums Written 1 Penal Sum/Face Value of Bail Bonds written in Nevada 1 Premium Taxes Due 1 Premiums and considerations 1 Taxable Life Insurance Premiums (Schedule A) 1 Total Funds on Hand as of 12/31/2010 1 Total Premiums/Consideration 10 Annual Naic Fee (Nevada $26) 10 Fees charges and other considerations not subject to tax 10 Funds applied to pay fees charges and other considerations 10 Funds used to pay death and other benefits 10 Industrial Insurance (Workers Compensation) Dividends 10 Premiums written in states in which the company is not licensed 10 Taxable Title premiums 10 Total Deductions 10 Total Premium Tax Due (Line 7 plus Lines 8 and 9) 11 15 11 Fees charges and other considerations not subject to tax 11 Filing Charter Documents (Nevada $10 each) 11 Funds applied to pay fees charges and other considerations 11 Other Title Fees and Service Charges (Informational) 11 Subtotal of all annuity premiums and other considerations received 11 Taxable Accident and Health Premiums 11 Taxable Life Insurance Premiums 11 Total decrease in Funds on Hand 12 Filing Power of Attorney (Nevada $5) 12 Funds on Hand as of 12/31/2011 12 Total decrease in Funds on Hand 12 Total Deductions 12 Total Surrenders 13 Amounts in excess of considerations received 13 Filing any other certificate form (Nevada $10 each) 13 Funds on Hand as of 12/31/2011 13 Taxable Property and Casualty Premiums 14 Deductible Surrenders 14 Filing Certificate of Compliance (Nevada 0 ) 15 Agent Licenses And Renewals (Nevada $15 $125) 15 Dividends paid in cash or left on deposit 1550 College Parkway Rm 115 16 20 16 Dividends applies to provide paid up annuities 16 Filing Rates and Forms @ $25 each 17 Filing Riders and Endorsements @ $10 each 17 Total Deductible Dividends 18 Taxable Annuity Premiums 2 $ @ % 2 Calculated Bail Premiums 2 Charges fees and other considerations not included in premiums 2 Fees charges and other considerations paid directly by policyholders 2 Finance and Service charges not included in premium 2 Gross Premium Tax (3 5% of Line 1 or 2% for RRG if qualified 2 Premiums written by Non Affiliated Agencies 2 Premiums written in states in which the company is not licensed 2 Taxable Accident and Health Premiums (Schedule B) 2 Total funds accepted during the year 2 Total funds accepted during the year excluding dividends for paid up 21 30 21 Total all Fees/Charges 22 Total Taxes and Fees 23 Retaliatory Assessment 3 $ @ % 3 Dividends applied to provide paid up annuities 3 Fees charges and other considerations paid directly by policyholders 3 Fees charges and other considerations paid directly by policyholders 3 Immediate annuities 3 Increase in gross income interest and dividends 3 Other fees charges and considerations 3 Premiums written by Affiliated Agencies 3 Taxable Annuity Premiums (Schedule C) 3a Home Office Credit if qualified (NRS 680B 050) 50% or 5 of Line 2 (Form PT 04 and required documents must be attached) 3b Amount of Ad Valorem Taxes Paid if qualified for Home Office Credit (NRS 680B 050 ) 3c Max Credit Allowed 3d Allowable Home Office Credits 4 $ @ % 4 Bail premiums and other considerations not reported on the State Page 4 Dividends applied to pay renewal premiums 4 Increase in gross income interest and dividends 4 Other charges fees and considerations paid directly by the policyholder 4 Other Income 4 Premiums written in states in which the Company is not licensed 4 Subtotal of Lines 1 3 4 Subtotal of Premium Tax Due for Calendar Year 20010 (Line 2 minus Line 3d) 4 Taxable Bail Premiums 4 Taxable Property and Casualty Premiums (Schedule D) 5 $ @ % 5 Accumulated Funds applied to annuitization 5 Fees charges and other considerations paid directly by policyholders 5 Life/Health Guaranty Association Offset (NRS 686C) 5 Other charges fees and considerations paid directly by the policyholder 5 Premiums fees charges and other considerations including installment 5 Taxable Title Premiums (Schedule E) 5 Total increase in Funds on Hand 5 Total Premiums and Considerations 5 Total Surety Premiums 6 $ @ % 6 Dividends paid in cash or left on deposit 6 Dividends paid or credited on Direct Business 6 Fees charges and other considerations 6 Funds returned prior to annuitization 6 Non Bail Surety Premiums 6 Premiums written in states in which the Company is not licensed 6 Property/Casualty Guaranty Association Credit (NRS 687A) 6 Total Direct Premiums Written 6 Total increase in Funds on Hand 680A 330) requires you to use the higher tax rate charged by your domiciliary state where applicable 7 Dividends applied to pay renewal premiums 7 Funds returned in excess of considerations received 7 Funds returned prior to annuitization 7 Net Premium Tax Due 7 Reported Bail Premiums 7 Social Security Act Title XVIII Premiums 7 Subtotal of Lines 5 and 6 7 Total Premiums and Considerations 7 Total Taxes Due 8 Dividends Paid or Credited to Policyholders 8 Dividends used to provide paid up additions or shorten endowment 8 Escrow and Settlement Service Charges 8 Federal Employee Health Benefits Premiums 8 Filing Annual Statement (Nevada $25) 8 Funds returned in excess of considerations received 8 Funds used to purchase annuities 8 Other Considerations 8 Penalty (See Instructions for rate) 8 Taxable Bail Premiums and Considerations not reported on the 9 Annual Licensing Fee (Nevada $2 450) 9 Daily Interest Premium Tax Due (Line 7) multiplied by 00049315068 times the number of days late 9 Dividends applied to provide paid up annuities 9 Fees charges and other considerations not subject to tax 9 Funds used to pay death and other benefits 9 Funds used to purchase annuities 9 Industrial Insurance (Workers Compensation) Premiums 9 Total Deductible Dividends A COPY OF THE NEVADA PAGE FROM THE ANNUAL STATEMENT MUST BE ATTACHED actual application of the money to the purchase of annuities but any interest credited to money accumulated while under the latter alternative Agent All title insurance reporters must indicate their state of domicile and basis on which they report their premiums to the state of domicile (all inclusive or risk rate) amount listed on Line 6 3 Column 5 of the Nevada State Page amount shown in Column B to page 2 (Summary of Schedules) Line 1 on Insurance Premium Tax Annual Return amount shown in Column B to page 2 (Summary of Schedules) Line 5 on Insurance Premium Tax Annual Return amount shown on Line 1 Column A of Supplemental Schedule 1 and Line 7 2 Column 5 of the Nevada State Page amount shown on Line 29 Column 4 of the NAIC Schedule T ANNUAL INSURANCE PREMIUM TAX RETURN 2012 ANNUAL INSURANCE PREMIUM TAX RETURN INSTRUCTIONS Annual Reconciliation Return Annual Reconciliation Return Page 2: annuities Annuity Election: Annuity Election: Front End: Date Election Approved by Commissioner: annuity or profit sharing plan qualified or exempt pursuant to sections 401 403 404 408 457 or 501 of the United States Internal Revenue Code any request for refund must be made within 1 year after the date such fees charges or taxes were originally required to be paid or within 30 days after the Assessment owed to the State of Nevada remit Retaliatory Assessment to the Department of Taxation If Column A is greater than Column B enter 0 B to Transfer the amount shown in Column B to page 2 (Summary of Schedules) Line 3 on Insurance Premium Tax Annual Return Back end Annuity NRS 680B 025(2) allows that money accepted by a life insurer pursuant to an agreement which provides for an accumulation of money to Back End: be performed in Nevada For Health companies the amount entered should match the amount listed on Line 29 Column 8 of the NAIC Schedule T For by contract basis with the net amount entered on this line calendar year 1971 or for the first calendar year it transacts business in this State whichever is later its election between those two alternatives Carson City NV 89706 7921 Column 5 of the NAIC Schedule T and Line 4 Column 5 of the Nevada State Page Column 5 of the Nevada State Page Column A Column A Column A Column A should include all premiums written and considerations received from annuity contracts issued in conjunction with the funding of a pension Column A Column A should include all premiums written and considerations received from life insurance contracts issued in conjunction with the funding of a Column A Column A should include those figures relating to Nevada risks only Column B Column B Column B Column B should include all premiums written and considerations received from annuity contracts not included in Column A Column B Column B should include all premiums written and considerations received from life insurance contracts not included in Column A Column B Column B should include those figures relating to all risks nationally Column C Column C Column C line items should be the sum total of Column A and Column B for each line item Column C should match the amount shown on Line 2 Column A of Supplemental Schedule 1 companies the amount entered should match the amount shown on Line 26 Column 3 less Line 24 1 Column 3 and Line 24 4 Column 3 of the Nevada companies the amount entered should match the amounts listed on Line 13 Column 1 through Line 15 7 Column 1 of the Nevada State Page considerations for accident and health insurance contracts received on account of policies and contracts covering property or risks located resident or to considerations for property and casualty insurance contracts received on account of policies and contracts covering property or risks located resident or contracts CONTRACTS ISSUED IN CONJUNCTION WITH TITLE XVIII MEDICARE OR THE FEDERAL EMPLOYEES HEALTH BENEFIT CONTRACTS PREVIOUSLY TAXED ON THE FRONT END ARE ELIGIBLE FOR A SURRENDER DEDUCTION The amount in Column C Contracts Taxed on a Back end basis Contracts Taxed on a Front end basis credit if you have applied for a refund NOTE: Only credits established by the Department may be used credited thereto is not subject to taxation upon the purchase of annuities Each life insurer shall signify on its return covering premiums for the Date Election Approved by Commissioner: date of payment of any additional tax charge or fee If you wish for the refund to be issued to a different address please provide a separate letter Date Rec d: declared and issued the dividend becomes the property of the policyholder and is deductible to the insurer The total in Column C should match the Departmental Use Only disallow any amounts on Line 10 if the explanation provided does not justify the deduction; penalty and interest will apply to any amounts disallowed disallow any amounts on Line 11 if the explanation provided does not justify the deduction; penalty and interest will apply to any amounts disallowed disallow any amounts on Line 9 if the explanation provided does not justify the deduction; penalty and interest will apply to any amounts disallowed DO NOT REMIT THESE FEES TO THE DEPARTMENT OF TAXATION doing business in your state DOMICILE OR A SEPARATE SCHEDULE ILLUSTRATING HOW THE TAX IN COLUMN B WAS CALCULATED Due Date earned through overpayment in the current or prior periods ATTACH A COPY OF THE TAX RETURN FILED IN YOUR STATE OF Email address of person Enrollment and Utilization entered should match the amount shown on Line 15 7 Column 1 of the Nevada State Page entered should match the amount shown on Line 16 Column 3 of the Nevada State Page event The amount in Column C should match the amount shown on Line 1 Column A of Supplemental Schedule 1 and Line 7 2 Column 5 of the Nevada explained in the write in lines of Schedule A will be disallowed and penalty and interest will apply The Department of Taxation reserves the right to explained in the write in lines of Schedule C will be disallowed and penalty and interest will apply The Department of Taxation reserves the right to explained in the write in lines of Schedule D will be disallowed and penalty and interest will apply The Department of Taxation reserves the right to explained in the write in lines of Schedule E will be disallowed and penalty and interest will apply The Department of Taxation reserves the right to Fax: (775) 684 2020 fees not reported on Schedule T figure and should not include surrenders dividends or fees charged against the contracts prior to annuitization The amount in Column C should match figure this is the amount of overpayment that may be refunded Enter the amount to be refunded in the box below Line 10 Pursuant to NRS 680B 120 For Health companies the amount entered should match the amount shown on Line 29 Column 5 of the NAIC Schedule T For Life & Health companies for proof of payment For Property & Casualty companies the amount entered should be included in the amount shown on Line 13 Column 1 of the Nevada State Page For Year Ending December 31 2011 Front End: I hearby declare under penalty of perjury that this premium tax report (including any accompanying schedules and statements) has been examined by If you are claiming this credit the insurer must provide certified copies of the billing by local authorities for the Ad Valorem taxes in addition to a receipt in Column C should match the amount listed on Line 29 Column 2 of the NAIC Schedule T and Line 1 Column 5 of the Nevada State Page in those states on this line; you must pay Nevada premium tax on these amounts as stipulated in NRS680B 035 insurance premiums written in those states on this line; you must pay Nevada premium tax on these amounts as stipulated in NRS680B 035 is not available and all premiums and considerations must be taxed on a front end basis Life & Health companies the amount entered should match the amount listed on Line 29 Column 4 of the NAIC Schedule T For Property & Casualty life insurance contracts received on account of policies and contracts covering property or risks located resident or to be performed in Nevada The total Line 1 Enter all direct accident and health insurance premiums written during the year (including policy membership and other fees and assessments) and all Line 1 Enter all direct life insurance premiums written during the year (including policy membership and other fees and assessments) and all considerations for Line 1 Enter all direct property and casualty insurance premiums written during the year (including policy membership and other fees and assessments) and all Line 1 Enter the amount of premium tax Line 1 Enter the amount of premiums and considerations received on annuity contracts which are not taxed on a back end basis as defined below The amount in Line 1 Enter the Penal Sum/Face Value of all bail bonds written in Nevada Line 1 Enter the Premium Tax Due on the Nevada basis in Column A This number can be found on Line 7 of your Annual Reconciliation Return Enter the Line 1 Enter the total funds on hand for the benefit of annuity contracts taxed on the back end as of December 31 2010 Line 1 Enter the total funds on hand for the benefit of annuity contracts taxed on the front end as of December 31 2010 Line 1 Enter the total premiums written on direct operations The amount entered should match the amount shown on Line 29 Column 3 of the Schedule T Line 1 Transfer the amount shown on Line 11 Column B from Schedule A to this line Line 10 Add Lines 7 8 and 9 and enter the result here This is the total amount of tax penalties and interest due If the calculated amount results in a negative Line 10 Enter all dividends paid in cash left on deposit or credited to policyholders for industrial insurance (workers compensation) contracts The amount Line 10 Enter all funds drawn from annuity accounts to pay fees charges and other considerations on behalf of the policyholder Line 10 Enter all funds used to pay death and other benefits on annuity contracts Line 10 Enter any fees charges or other considerations included on Lines 1 through 3 above which you believe are not subject to taxation Any amounts claimed Line 10 Enter the sum total of Lines 6 through 9 Line 10 If you are domiciled in Nevada and doing business in states in which you are not licensed and do not pay premium tax enter the annuity premiums written Line 10 Subtract Line 8 and Line 9 from Line 7 and enter the difference here; this is your total Taxable Title Premium Transfer the amount shown to Transfer the Line 11 Add Lines 6 8 9 and 10 and subtract Line 7 and enter the total here Line 11 Enter all funds drawn from annuity accounts to pay fees charges and other considerations on behalf of the policyholder Line 11 Enter any fees charges or other considerations included on Lines 1 through 5 above which you believe are not subject to taxation Any amounts claimed Line 11 Enter the amount of other title fees and service charges subject to tax The amount entered should equal that portion of Line 3 Column 4 from the NAIC Line 11 Enter the sum total of Lines 4 7 8 9 and 10 Line 11 Subtract Line 10 from Line 5 and enter the difference here; this is your total Taxable Accident & Health Premiums Transfer the amount shown to Line 11 Subtract Line 5 and Line 10 from Line 9; this is your total Taxable Life Insurance Premiums Transfer the amount shown in Column B to Transfer the Line 12 Add Lines 1 and 5 and subtract Line 11 and enter the total here Line 12 Add Lines 7 9 10 and 11 and subtract Line 8 and enter the total here Line 12 Add Lines 8 9 and 11 and subtract Line 10 and enter the total here Line 12 Enter the amount of funds returned to policyholders as a result of contract surrenders prior to annuitization ONLY CONTRACTS PREVIOUSLY Line 13 Add Lines 1 and 6 and subtract Line 12 and enter the total here Line 13 Enter the amount of funds returned to policyholders in excess of premiums paid as a result of contract surrenders prior to annuitization ONLY Line 13 Subtract Line 11 from Line 7 and enter the difference here; this is your total Taxable Property and Casualty Premium Transfer the amount shown to Line 14 Subtract Line 13 from Line 12 and enter the difference here Line 15 Enter all dividends paid in cash to the policyholder or left on deposit in the policyholder s name The total in Column C should match the amount listed Line 16 Enter all dividends used to provide paid up additions of life insurance or shorten the endowment period for life insurance contracts Once a dividend is Line 17 Enter the sum total of Lines 15 and 16 Line 18 Subtract Lines 14 and 17 from Line 11 and enter the difference here; this is your total Taxable Annuity Premiums Transfer the amount shown in Column Line 2 Enter all charges fees and considerations for accident and health insurance not paid directly by the policyholder and not included on Line 1 above Line 2 Enter all finance and service charges not included in premiums The amount entered should match Line 29 Column 8 of the NAIC Schedule T Line 2 Enter all funds received during the tax year from policyholders for the payment of premiums considerations fees and charges for the benefit of annuity Line 2 Enter the amount of charges fees and considerations paid directly by the policyholder and not included on Line 1 above The amount in Column C Line 2 Enter the total premiums written by non affiliated agencies The amount entered should match the amount shown on Line 29 Column 4 of the Schedule Line 2 If you are domiciled in Nevada and doing business in states in which you are not licensed and do not pay premium tax enter the life insurance premiums Line 2 Multiply line 1 by 0 035 and enter the result here If you are a Risk Retention Group multiply Line 6 by 0 02 instead and enter the result here Line 2 Multiply Line 1 by 0 15 (15%) and enter the product here Line 2 Transfer the amount shown on Line 11 from Schedule B to this line Line 24 Add Lines 8 23 and enter the total here Line 25 Add Lines 7 and 24 and enter the total here Line 26 Compare Line 25 Column A to Column B If Column B is greater than Column A enter the difference here This is the amount of Retaliatory Line 3 Enter all charges fees and considerations charged on bail bond contracts Line 3 Enter all charges fees and considerations for accident and health insurance paid directly by the policyholder and not included on Line 1 above Line 3 Enter all dividends applied to provide paid up annuities The amount entered should match the amount shown on Line 7 2 Column 5 of the Nevada State Line 3 Enter all fees charges and considerations for property and casualty insurance paid directly by the policyholder and not included in Line 1 above Line 3 Enter all fees charges and other considerations for life insurance paid directly by the policyholder and not included on Line 1 above Line 3 Enter the amount of premiums and considerations received for the purchase of immediate annuities Due to the nature of immediate annuities tax deferral Line 3 Enter the income interest and dividends earned on annuity premiums on deposit Line 3 Enter the total premiums written by affiliated agencies The amount entered should match the amount shown on Line 29 Column 5 of the Schedule T Line 3 Transfer the amount shown on Line 18 Column B from Schedule C to this line Line 3a If you maintain a home or regional office in Nevada and have been approved by the Department of Taxation as described by NRS 680B 050 you Line 3b If you maintain a home or regional office in Nevada and have been approved by the Department of Taxation as described by NRS 680B 050 you Line 3c Multiply Line 7 by 0 8 and enter the result here Line 3d Enter the lesser of Lines (3a + 3b) or Line 3c Line 4 Enter all dividends used to provide paid up additions of life insurance or shorten the endowment period for life insurance contracts Exchanging dividend Line 4 Enter all other fees charges and considerations paid directly by the policyholder and not included in Line 2 above Line 4 Enter all taxable premiums and considerations for bail contracts not included on Line 1 above The amount entered should match the amount shown on Line 4 Enter the amount of other income attributable to Nevada policies The amount entered should match the amount shown on Line 29 Column 6 of the Line 4 Enter the income interest and dividends earned on annuity premiums on deposit Line 4 Enter the sum total of Line 2 and 3 Line 4 Enter the sum total of Lines 1 through 3 Line 4 If you are domiciled in Nevada and doing business in states in which you are not licensed and do not pay premium tax enter the accident and health Line 4 Subtract Line 3d from Line 2 and enter the result here Line 4 Transfer the amount shown on Line 13 from Schedule D to this line Line 5 Enter all fees charges and considerations for title insurance paid directly by the policyholder and not included in Lines 1 through 4 above Line 5 Enter all other fees charges and considerations paid directly by the policyholder and not included in Line 2 above Line 5 Enter all premiums fees charges and considerations including installment and membership fees not reported on NAIC Schedule T and not included on Line 5 Enter all surety premiums written in Nevada The amount entered should match the amount shown on Line 24 Column 1 of the Nevada State Page Line 5 Enter the amount of Life/Health Guaranty Association Offset here as allowed by NRS 686C Line 5 Enter the sum total of Lines 1 through 4 Line 5 Enter the sum total of Lines 2 through 4 Line 5 Enter the total influx of funds received during the lifetime accumulation period for deferred annuities which annuitized during the tax year This is a gross Line 5 Transfer the amount shown on Line 10 from Schedule E to this line Line 6 Enter all dividends paid in cash to the policyholder or left on deposit in the policyholder s name The total in Column C should match the amount listed Line 6 Enter all funds returned to the policyholder prior to annuitization Do not include any amounts retained for surrender charges Line 6 Enter all surety premiums written in Nevada for all non bail contracts Line 6 Enter the amount of dividends paid or credited to policyholders on direct business written DO NOT INCLUDE DIVIDENDS PAID ON Line 6 Enter the amount of fees charges and other considerations charged against accounts in the tax year The amount in Column C should match the amount Line 6 Enter the amount of Property/Casualty Guaranty Association Offset here as allowed by NRS 687A Line 6 Enter the sum total of Lines 1 through 5; this is your Total Direct Premiums Written Transfer the amount shown to Line 1 of the Annual Insurance Line 6 Enter the sum total of Lines 2 through 5 Line 6 If you are domiciled in Nevada and doing business in states in which you are not licensed and do not pay premium tax enter the property and casualty Line 6 If you are domiciled in Nevada and doing business in states in which you are not licensed and do not pay premium tax enter the title insurance premiums Line 7 Add Lines 1 6 and enter the total here Line 7 Enter all dividends applied to pay renewal premiums on the policyholder s behalf The total in Column C should match the amount listed on Line 6 2 Line 7 Enter all funds returned to the policyholder prior to annuitization Do not include any amounts retained for surrender charges Line 7 Enter the amount of funds returned to the policyholder prior to annuitization that exceeded premiums paid This calculation must be done on a contract Line 7 Enter the amount of premiums received from the Secretary of Health and Human Services pursuant to a contract entered into pursuant to section 1876 of Line 7 Enter the sum total of Lines 1 through 6 Line 7 Enter the sum total of Lines 5 and 6 Line 7 Subtract Line 6 from Line 5 and enter the difference here Line 7 Subtract lines 5 A from line 4 and enter the result here Line 8 Enter all dividends paid in cash left on deposit or credited to policyholders for property and casualty contracts The amount entered should match the Line 8 Enter all dividends used to provide paid up additions of life insurance or shorten the endowment period for life insurance contracts Once a dividend is Line 8 Enter all funds used to purchase annuities Line 8 Enter all other considerations received on all annuity contracts during the tax year The amount in Column C should match the amount shown on Line 29 Line 8 Enter the amount of escrow and settlement service charges not subject to tax The amount entered should equal that portion of Line 2 Column 4 from the Line 8 Enter the amount of funds returned to the policyholder prior to annuitization that exceeded premiums paid This calculation must be done on a contract Line 8 Enter the amount of premiums received pursuant to a contract entered into pursuant to the Federal Employees Health Benefit Plan 5USC Sec 8909f1 Line 8 If this return and payment are not submitted/received with a postmark on or before the date on the front of this return penalty may apply If line 7 is a Line 8 of Supplemental Schedule 3 Line 8 Subtract Line 7 from Line 4 and enter the difference here; this is your total Taxable Bail Premiums and Considerations not reported on the Nevada State Line 9 Enter all dividends used to provide paid up annuities Exchanging dividend proceeds for paid up annuities is consideration for insurance and a taxable Line 9 Enter all funds used to pay death and other benefits on annuity contracts Line 9 Enter all funds used to purchase annuities Line 9 Enter all premiums written on industrial insurance (worker s compensation) contracts during the tax year The amount entered should match the amount Line 9 Enter any fees charges or other considerations included on Lines 1 through 3 above which you believe are not subject to taxation Any amounts claimed Line 9 Enter any fees charges or other considerations included on Lines 1 through 5 above which you believe are not subject to taxation Any amounts claimed Line 9 Enter the sum total of lines 6 through 8 Line 9 If this return and payment are not submitted/received with a postmark on or before the date on the front of this return interest may apply If line 7 is a Line A Enter the amount due to you for Overpayment in the prior year for which you have received a Department of Taxation Credit Notice Do not take the Line B Enter the amount of refund you received from the State of Nevada during the 2010 calendar year Line Enter the line number in the Annual Statement or Separate Accounts Statement from which the figure is derived Lines 1 2 or 3 above Lines 2 6 Include any additional taxes or assessments (include Fire Marshall Ocean Marine or other state or municipal tax) that are levied on a Nevada company Lines 20 23 Enter any additional fees that are levied on a company doing business in your state not enumerated here Lines 8 19 Enter the fees levied by Nevada and your state of domicile in the appropriate Line and Column March 15 2013 me and is true correct and complete report must also be included in total income derived from direct premiums written and any money taxed upon receipt including any interest later NAIC Operations and Investments Exhibit Part 1A Summary of Title Insurance Premiums Written and Related Revenues which are attributable to NAIC Schedule T For Life & Health companies the amount entered should match the amount shown on Line 24 4 Column 1 of the Nevada State Page National Nevada Nevada Department of Taxation Nevada Department of Taxation Annual Reconciliation Return pg 2 Nevada policies Non Qualified NRS REQUIRES THIS RETURN MUST BE SIGNED Number of Days Late on Line 10 must be explained in the write in lines of Schedule A; attach additional pages if necessary Any amounts claimed on Line 10 which are not on Line 11 must be explained in the write in lines of Schedule D; attach additional pages if necessary Any amounts claimed on Line 11 which are not on Line 6 1 Column 5 of the Nevada State Page on Line 7 1 Column 5 of the Nevada State Page on Line 7 Column A of Supplemental Schedule 1 on Line 9 must be explained in the write in lines of Schedule C; attach additional pages if necessary Any amounts claimed on Line 9 which are not on Line 9 must be explained in the write in lines of Schedule E; attach additional pages if necessary Any amounts claimed on Line 9 which are not Operations and Investments Exhibit Part 1A Summary of Title Insurance Premiums Written and Related Revenues which are attributable to Nevada Page Enter the page number in the Annual Statement or Separate Accounts Statement from which the figure is derived Page Transfer the amount shown to Schedule D Line 4 Penalty Factor pension annuity or profit sharing plan qualified or exempt pursuant to sections 401 403 404 408 457 or 501 of the United States Internal Revenue period Phone: (775) 684 2000 PLAN For Health companies the amount entered should be included in the amount shown on Line 9 of the Statement of Cash Flows For Life & Health Policies INFORMATIONAL LINE ONLY positive number multiply that number by the corresponding Penalty Factor below: positive number multiply that number by the number of days the payment is past due times 0 00049315068 Premium Tax Due in your state of domicile in Column B This amount should not include any Guaranty Association offsets/credits or offsets/credits Premium Tax Return Printed Name of Taxpayer or Authorized proceeds for paid up additions or to shorten the endowment period of a life insurance contract is consideration for insurance and a taxable event The property in the insurer s name on file with the Department of Taxation purchase annuities at future dates may be considered as total income derived from direct premiums written either upon receipt or upon the Qualified qualify for this credit Enter the amount of Ad Valorem taxes paid during the calendar year upon the home office or regional office together with the land qualify for this credit Multiply Line 7 by 0 5 and enter the result here If you are claiming this credit you must have a certified copy of the deed to the refunded requesting that the refund be issued to a different address and a contact persons credentials responsible for completing return Retaliatory worksheet Schedule A Life Insurance Premiums Schedule B Accident and Health Premiums Schedule C Annuity Premiums Schedule D Property and Casualty Premiums Schedule E Title Premiums Schedule T as well as the sum of Line 8 and Line 10 on this schedule Schedule T For Health companies the amount entered should match the amount listed on Line 14 Column 1 of the Nevada Exhibit of Premiums should match the amount shown on Line 5 Column A of Supplemental Schedule 1 should match the amount shown on Line 8 Column A of Supplemental Schedule 1 shown on Line 10 Column A of Supplemental Schedule 2 shown on Line 16 Column 1 of the NAIC Schedule T Signature of Taxpayer or Authorized State of Domicile State of domicile requires Title premiums to be reported on the: State Page State Page Summary of Schedules Supplemental Schedule 1 Accounting of Funds on the Front end Supplemental Schedule 2 Accounting of Funds on the Back end Supplemental Schedule 3 Bail Bonds Tax Identification No: TAXED ON THE BACK END TAXED ON THE FRONT END TAXED ON THE FRONT END ARE ELIGIBLE FOR A SURRENDER DEDUCTION The amount in Column C should match the amount shown Taxpayer ID: F2 F3 Taxpayer ID: F2 F3 Taxpayer ID: F2 F3 Telephone the amount entered should match the amount shown on Line 24 1 Column 1 of the Nevada State Page For Property & Casualty companies the amount the amount shown on Line 8 Column A of Supplemental Schedule 2 the Social Security Act 42USC Sec 1395mm For Health companies the amount entered should match the amount shown on Line 29 Column 3 of the Thereafter an insurer shall not change his or her election without the consent of the Commissioner This annual return is a summary of the calendar year The Nevada premium tax rate is 3 5% or 2% for Risk Retention Groups if qualified Retaliatory statutes (NRS THIS SUPPLEMENTAL SCHEDULE MUST BE COMPLETED BY ANY COMPANY WRITING ANNUITY BUSINESS WITH SOME PREMIUMS THIS SUPPLEMENTAL SCHEDULE MUST BE COMPLETED BY ANY COMPANY WRITING BAIL BOND BUSINESS to be performed in Nevada For Property & Casualty companies the amount entered should match the amount listed on Line 29 Column 1 of the NAIC Total total in Column C should match the amount listed on Line 6 3 Column 5 of the Nevada State Page Transfer the amount shown in Column B to page 2 (Summary of Schedules) Line 2 on Insurance Premium Tax Annual Return Transfer the amount shown in Column B to page 2 (Summary of Schedules) Line 4 on Insurance Premium Tax Annual Return Write In Lines: written in those states on this line; you must pay Nevada premium tax on these amounts as stipulated in NRS680B 035