Form IP-2 Fillable Captive Insurance Premium Tax Return
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

1 Gross direct premiums collected or contracted for 1 $ 10 TOTAL TAX (add Lines 8 & 9) 10 $ 11 If the amount on Line 10 is more than $200 000 enter $200 000 12 If this is the first year of license in Vermont enter $7 500 for tax credit per 8 V S A 6014(k) 12 $ 13 TAX DUE Subtract Line 12 from Line 11 133 State Street 14 Assumed Reinsurance Premiums collected or contracted for 14 $ 15 Other charges (please specify) 15 $ 16 TOTAL ASSUMED REINSURANCE PREMIUMS (add Lines 14 & 15) 16 $ 17 Return premiums 17 $ 18 Other deductions (please specify) 18 $ 19 TOTAL DEDUCTIONS (add Lines 17 & 18) 19 $ 2 Other charges (please specify) 2 $ 20 NET ASSUMED REINSURANCE PREMIUMS (subtract Line 19 from Line 16) 20 $ 21 Enter amount due from Tax Rate Schedules (enter here and on Line 9 on front of form) 21 $ 3 TOTAL PREMIUMS (add Lines 1 & 2) 3 $ 4 Return Premiums 4 $ 5 Other deductions (please specify) 5 $ 6 TOTAL DEDUCTIONS (add Lines 4 & 5) 6 $ 7 NET TAXABLE PREMIUMS (subtract Line 6 from Line 3) 7 $ 8 TAX on Direct Insurance Premiums (See Direct Rate Schedule on reverse side) 8 $ 9 TAX on Reinsurance Premiums from Line 21 (reverse side) 9 $ Form IP 2 Make checks payable to: VERMONT DEPARTMENT OF TAXES 13 $ $ Montpelier VT 05601 0547 Montpelier VT 05633 1401 PO Box 547 Print or type complete name and address below: VT Department of Taxes 133 State Street; PO Box 547; Montpelier VT 05601 0547 42 U S C 405(c)(2)(C) and used to identify taxpayers affected aggregate tax to be paid by a sponsored insurance company shall All direct premiums written by a Vermont Captive regardless of and control if the transaction is part of a plan to discontinue the and other liabilities of another insurer under common ownership apply to each protected cell only and not to the sponsored captive ASSUMED RATE by Vermont tax laws captive insurance company Attach a list of all captive insurance Common ownership and companies included on the return COMPUTATION OF TAX DUE ON DIRECT INSURANCE COMPUTATION OF TAX DUE ON REINSURANCE WORKSHEET control means in the case of stock corporations the direct or indirect ownership of 80% or more of the outstanding voting stock corporations by the same member(s) Date first licensed to do business in VT: Date Organized: DIRECT RATE excess over $20 million is 00143 excess over $20 million is 00285 excess over $40 million is 00048 excess over $40 million is 0019 Fed ID # For assistance call: (802) 828 2551 option 4 Miscellaneous Tax Division For tax year I hereby certify this return is true correct and complete to the best of my knowledge If Line 20 is $20 million or less multiply Line 20 by 00214 If Line 7 is $20 million or less multiply Line 7 by 0038 If sending via courier service (UPS FedEx DHL etc ): If sending via US Mail: If the amount on Line 10 is less than $7 500 enter $7 500 INSTRUCTIONS insurance company as a whole 8 V S A 6014(c) maintain such business with the captive insurance company maximum aggregate tax shall be $200 000 00 The maximum Miscellaneous Tax Division No reinsurance premium tax is payable in connection with the of 80% or more of the surplus and voting power of two or more operations of that insurer and if the parties intend to renew or or two or more corporations by the same shareholder(s) and in Otherwise enter the amount from Line 10 11 $ $ Over $20 million but not more than $40 million tax rate for the Over $40 million but not more than $60 million tax rate for the Over $60 million tax rate for the excess over $60 million is 00024 Over $60 million tax rate for the excess over $60 million is 00072 ownership and control may file a single return and pay tax as a single Phone: (802) 828 2551 receipt of assets in exchange for the assumption of loss reserves Return due annually on or before the last day of February Returns are subject to a minimum tax of $7 500 00 The annual Rev 10/11 SEND COMPLETED RETURN TO: Signature of Preparer Other Than Officer Printed Name Signature of Responsible Officer Printed Name Title Date TAX RATE SCHEDULES the case of mutual corporations the direct or indirect ownership The disclosure of your SSN or FID# is mandatory authorized by their taxability in another state are subject to tax by Vermont Title/Firm Name Preparer s Telephone Number Date Two or more captive insurance companies under common Under the laws of the State of: UNSIGNED RETURNS WILL BE RETURNED Vermont Vermont Department of Taxes VT CAPTIVE INSURANCE PREMIUM TAX RETURN