Free 2006 Utah Insurance Premium Tax Return, TC-49 - Utah

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Utah State Tax Commission 210 N 1950 W · SLC, UT 84134 · www.tax.utah.gov

TC-49
Rev. 12/06

Insurance Premium Tax Return
Find TC-49 Instructions at this site.
Name and address (please correct any errors)

FEIN/Account Number
Use this number for all references

Start below this line. Enter your company name and address.

Tax Period

Return due on or before

Round to whole dollar amounts 1. Gross tax due (amount from Schedule A, line 36 or 37, whichever is greater, but not less than zero) ................ 2. Occupational health and safety credit (see instructions) ............................. 3. Utah based companies only. Examination fees (attach schedule)............... 4. Guaranty Association credit (please note restrictions in the instructions) ... 5. Total credits (add lines 2 through 4) ............................................................ 2 3 4 5 00 00 00 00 6 7 8 00 00 00 1 00

INS

6. Allowable credits (lesser of line 1 or line 5, but not less than zero) ...................................................................... 7. Previous Guaranty Association Credit Refunds (see instructions) ....................................................................... 8. Total tax due (line 1 less line 6 plus line 7). If less than zero, enter "0" ................................................................ 9. Prepayments a. Guaranty Association refunds remitted ....................... b. Refund applied from prior years.................................. c. First quarter................................................................. d. Second quarter ........................................................... e. Third quarter ............................................................... 9a 9b 9c 9d 9e 00 00 00 00 00

10. Total prepayments (add lines 9a through 9e)........................................................................................................ 11. TAX DUE WITH RETURN (if line 8 is greater than line 10, subtract line 10 from line 8 and enter amount) ......... 12. OVERPAYMENT (if line 10 is greater than line 8, subtract line 8 from line 10 and enter amount) ....................... Check box at right if you want refund applied to tax for 2007................................................................

10 11 12

00 00 00

DO NOT INCLUDE UTAH STATE INSURANCE DEPARTMENT FEES WITH THIS RETURN.
I declare under the penalties provided by law that to the best of my knowledge this is a true, complete and correct return.
Authorized Signature Return Prepared By Date Date Telephone Telephone

Make a copy for your records. Return ENTIRE form, coupon and payment to the Utah State Tax Commission.
INSURANCE PREMIUM TAX RETURN ­ TC-49
Federal ID Number Filing Period Due Date
TC-49_1.ai Rev. 12/06

Amount Paid

00
Make check or money order payable to the Utah State Tax Commission. Do not send cash. Do not staple check to this coupon. Detach check stub.

Enter business name:

UTAH STATE TAX COMMISSION INSURANCE PREMIUM TAX RETURN 210 N 1950 W SLC UT 84134-0130
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Utah Insurance Premium Tax Return -- Schedule A
Annual Report Totals.

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TC-49A (TC-49_2.ai) Rev. 12/06

Include an 8 1/2" x 11" copy of the Utah business page and/or Schedule T of the Annual Report with this return.

1. Life insurance companies. Enter the total from the Utah business page. ................................. 2. Property and casualty insurance companies. Enter the total from the Utah business page. .... 3. Other insurance companies. Enter the total amount from your annual statement of premiums written in Utah. ........................................................................................................

1 2 3

$ $ $

00 00 00

Premiums received from direct business in Utah
4a Life/variable life insurance (see instructions) 4b Remaining variable life insurance (attach schedule of all variable life insurance premiums) .............................. 5. Annuity ................................................... 6. Health care ............................................. 7. Other disability........................................ 8. Fire including allied lines ........................ 9. Other than fire including allied lines ....... 10. Motor vehicle liability, personal injury protection, uninsured motorists .............. 11. Motor vehicle physical damage (non-fire portion)..................................... 12. Motor vehicle damage (fire portion)........ 13. Ocean marine......................................... 14. Other (specify): ____________ 15. Interest and service charges .................. 16. Base Premiums (add lines 4a through 15) 17. Title insurance ........................................ 4a 00

Deductions
21. Base Premiums (from line 16 at left) .... 22. Qualifying health care premiums............ 23. Annuity premiums (from line 5 at left)..... 24. Ocean marine premiums (from line 13).. 25. Premiums from Utah institutions of higher education (excluding worker's compensation premiums) ....................... 26. Qualifying dividends on life insurance .... 27. Qualifying dividends on fire and allied lines .... 28. Qualifying dividends on premiums other than life and fire (does not apply to worker's compensation).......................... 29. Total deductions (add lines 22 through 28) 30. Net taxable premiums (total base premiums line 21 less line 29)................ 21 22 23 24 25 26 27 28 29 30 00 00 00 00 00 00 00 00 00 00

4b 5 6 7 8 9 10 11 12 13 14 15 16 17 18a 18b 19 20

00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00

Tax Computation

If amount is less than zero, enter "0." 31 32 33 34 35 00 00 00 00 00

31. All other worker's compensation (multiply line 19 by .0775)....................... 32. Base premium tax (multiply line 30, less line 4b, by .0225)................................... 33. Utah variable life (line 4b) times .0008 ... 34. Auto insurance value study tax (multiply line 10 by .0001) ..................................... 35. Title insurance tax (multiply line 17 by .0045) .....................................................

Worker's Compensation
18a All agencies ............................................ 18b Deductibles (see instructions) ................ 19. Total of lines 18a and 18b ...................... 20. Total premiums (add lines 16, 17 and 19) Should agree with line 1, 2 or 3 above. .. See instructions if amounts do not agree.

Gross Tax Due
36. Tax due on Utah basis (add lines 31 through 35)..................................................................... 37. Tax due on retaliatory basis ................................................ State of Domicile
For retaliatory computation -- attach separate page if more space is needed for computation.

36 37

00 00

..

DO NOT ENTER ANYTHING BELOW THIS LINE
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