Medical Malpractice Attorney in New Hampshire

Document Sample
Medical Malpractice Attorney in New Hampshire Powered By Docstoc
					11/24/2010 13:42                               STATE OF NEW HAMPSHIRE DEPARTMENT OF INSURANCE
P&C ELECT PT FORM                               21 SOUTH FRUIT STREET, SUITE 14, CONCORD NH 03301
Rev 10/31/2008
                                                 STATEMENT OF FEES, CHARGES, AND PREMIUM TAXES
                                                         YEAR ENDED DECEMBER 31, 2008
                                                                 MARCH 15, 2009



                                        NEW HAMPSHIRE ALLOCATION OF PREMIUMS WRITTEN

NH RSA 400-A:31 Taxable Premiums: Gross Direct Premiums/considerations from policies covering property, subjects, or risks located,
resident or to be performed in this state, other than premiums received for reinsurance, including all dividends applied to purchase additional
insurance, membership and policy writing fees, etc., less return premiums/considerations only.




FILING INSTRUCTIONS:

Produce a NH state page
Complete state page worksheet
Complete the state of domicile basis for premiums written and premium tax.
Enter any business tax credits in the appropriate spaces.
Enter prior year credits applied and cash payments.
Complete Pages one and two of the premium tax return.
Attach the company's schedule T and NH state page to the tax return.
Attach a copy of the company's 2007 Business Enterprise Tax return if applicable.
Attach documentation for any "Other Deductions" the company may have taken.
Save electronic copy for the company's files.
Print copy of all pages to file with NH Insurance Department.

METHOD OF PAYMENT

Payment by EFT - EFT should be deposited in the Insurance Department bank account on or before March 16, 2009.
The hardcopy premium tax return should be mailed to NH Insurance Department to arrive not later than March 16, 2009.
Payment by check - Enclose check with a printed copy of completed premium tax return and mail to the address indicated above.
Timely mailing provisions apply. See RSA 400-A:32-a.



See Separate Instructions
The premium tax statement and payment of taxes is due NOT LATER THAN MARCH 16, 2009.




                                                    D:\Docstoc\Working\pdf\e266a893-eeda-4ad6-9e7b-5f40c356883e.xls Filing Instr 11/24/2010
11/24/2010 13:42                     STATE OF NEW HAMPSHIRE DEPARTMENT OF INSURANCE
P&C ELECT PT FORM                     21 SOUTH FRUIT STREET, SUITE 14, CONCORD NH 03301
Rev 10/31/2008                                         MARCH 15, 2009

                                      STATEMENT OF FEES, CHARGES, AND PREMIUM TAXES
                                                 RISK RETENTION GROUPS
                                              YEAR ENDED DECEMBER 31, 2008



COMPANY NAME
STREET, CITY, STATE & ZIP
TYPE OF COMPANY                                                                                                                      RRG
FEDERAL TAX ID NUMBER
NAIC GROUP CODE
NAIC COMPANY CODE
STATE OF DOMICILE (2 DIGIT ABBREVIATION)


PLEASE INDICATE METHOD AND AMOUNT OF TAX PAYMENT                                                      EFT
                                                                                                      CHECK



DID THIS COMPANY AMEND ITS BYLAWS DURING CY 2008?                                                     Y/N
DID THIS COMPANY AMEND ITS ARTICLES OF AGREEMENT DURING CY 2008?                                      Y/N


                                                               SWORN STATEMENT (RSA 400-A:31)
State of
County of
Name of Officer                                                                                       being duly sworn, deposes and says:
that he/she is the                                                                                    , of the

and that the following is a full, true and correct statement of the business done in the State of New Hampshire by said
Company during the year ending December 31, 2008.


Subscribed and sworn to before me this ______________ day of ____________________2009.


Officer


Notary Public



PLEASE INDICATE THE NAME OF THE TAXATION OFFICER WHOM WE SHOULD CONTACT IF THERE ARE QUESTIONS
ABOUT THIS FORM. ALSO INDICATE THE APPROPRIATE ADDRESS FOR CORRESPONDENCE, REFUNDS, ETC.

PREMIUM TAX CONTACT PERSON
ADDRESS (If different from above)
E-MAIL ADDRESS
PHONE NUMBER                                                                                          EXT
FAX NUMBER


See Separate Instructions
The premium tax statement and payment of taxes is due NOT LATER THAN MARCH 16, 2009.




                                                                  PAGE #1
COMPANY NAME
NAIC COMPANY CODE
STATE OF DOMICILE
YEAR ENDED DECEMBER 31, 2008

PREMIUM TAX FIRE AND CASUALTY COMPANIES - RETALIATORY PROVISION NH RSA 400-A:35
                              (1)                                    (2)                                        (3)          (4)
                                                                                                             STATE OF    LARGER OF
LICENSING, FILING AND DOCUMENT FEES ONLY                                                  NH BASIS           DOM BASIS    COL 2 OR 3
1. Certificate of Authority Renewal                                                                   0.00

2. Annual Filing Fees
   a) Annual Statement                                                                             100.00
   b) Certificate of Compliance                                                                      5.00
   c) Certificate of Deposit                                                                         5.00
3. Other Fees which might be applicable
   a) By-Laws (ONLY if amending)                                                                     25.00
   b) Articles of Incorporation (ONLY if amending)                                                   10.00
   c) Other Retaliatory Fees (itemize)
      Publication Fee                                                                       XXXXX
      Annual Statement Audit Fee                                                            XXXXX
      Other Fees - Attach Schedule                                                          XXXXX
4. TOTAL FILING FEES                                                                                          XXXXX



                                                                                                             STATE OF
OTHER TAXES, FEES, AND ASSESSMENTS                                                        NH BASIS           DOM BASIS      TAX

Calculation of taxes based upon laws governing state of domicile (Include % rate and basis if applicable).

5. FRANCHISE TAX                                                                            XXXXX
(If subject to a minimum, include this minimum amount $__________)                          XXXXX
6. CORPORATE TAX                                                                            XXXXX
7. DISTRICT/MUNICIPALITY                                                                    XXXXX
8. COUNTY/CITY/CANADIAN PROVINCE TAX                                                        XXXXX
9. WORKER'S COMPENSATION ADMIN ASSESSMENTS
10. WORKER'S COMPENSATION SECOND INJURY FUND
11. FIRE MARSHAL TAX                                                                        XXXXX
12. FIREMEN'S PENSION FUND                                                                  XXXXX
13. MOTOR VEHICLE                                                                           XXXXX
14. CASUALTY MAINTENANCE TAX                                                                XXXXX
15. COST CONTAINMENT FEES                                                                   XXXXX
16. FINANCIAL REGULATION FEE                                                                 XXXX
17. STATE RATING BUREAU                                                                      XXXX
18. MERIT RATING BUREAU                                                                      XXXX
19. ATTORNEY GENERAL                                                                         XXXX
20. FRAUD                                                                                    XXXX
21. ACTUARY                                                                                  XXXX
22. RATE HEARING                                                                             XXXX
23. POLICE PENSION FUND                                                                      XXXX
24. ARSON CONTROL                                                                            XXXX
25. INSURANCE DEPARTMENT MAINTENANCE
26.                                                                                         XXXX
27.                                                                                         XXXX
28.                                                                                         XXXX
29.                                                                                         XXXX
30.                                                                                         XXXX
31.                                                                                         XXXX
32.                                                                                         XXXX
33.                                                                                         XXXX
34.                                                                                         XXXX
35. OTHER - Attach Schedule                                                                 XXXX
36. TOTAL OTHER TAXES, FEES, & ASSESSMENTS                                               XXXXXXXXX           XXXXXXXXX




                                                                                PAGE #2
COMPANY NAME
NAIC COMPANY CODE
STATE OF DOMICILE
YEAR ENDED DECEMBER 31, 2008


PREMIUM TAX FIRE AND CASUALTY COMPANIES - RETALIATORY PROVISION NH RSA 400-A:35



NH RSA 400-A:31 Taxable Premiums: Gross Direct Premiums/considerations from policies covering property, subjects, or risks
located, resident or to be performed in this state, other than premiums received for reinsurance, including all dividends applied
to purchase additional insurance, membership and policy writing fees, etc., less return premiums/considerations only.


                                              (1)                                           (2)                     (3)                  (4)
                                                                                         NH BASIS                   ST OF DOM BASIS
GROSS PREMIUMS WRITTEN & TAXABLE CONSIDERATIONS                                         Prem Written   App Tax Rate     Prem Written     TAX
1. Property & Casualty Premiums Written
2. Accident & Health Premiums Written
3. Total Premiums Written Per Schedule T                                                                 XXXXXX         XXXXXX         XXXXXX
4. Finance & Service Charges - Property & Casualty Premiums Written
5. Finance & Service Charges - Accident & Health Premiums Written
6. Other Taxable Considerations - Property & Casualty
7. Other Taxable Considerations - Accident & Health
8. Unallocated Premiums Written - P&C (NH Domiciled)                                                    XXXXXX          XXXXXX          XXXXXX
9. Unallocated Premiums Written - A&H (NH Domiciled)                                                    XXXXXX          XXXXXX          XXXXXX
10. Gross Premiums/Considerations Written                                                               XXXXXX                         XXXXXXX

DEDUCTIONS FROM GROSS PREMIUMS P&C
11. Dividends Paid or Credited to Policyholders - Property & Casualty
12. Multiple Peril Crop Premiums Written (Net of Dividends to Policyholders)
13. Ocean Marine Premiums Written (Net of Dividends to Policyholders)
14. Other deductions - P&C (Provide complete documentation)
15. Total Deductions - P&C                                                                              XXXXXX

DEDUCTIONS FROM GROSS PREMIUMS A&H
16. Dividends Paid or Credited to Policyholders - Accident & Health
17. Fed Emp Health Benefit Premiums Written (Net of Div to Policyholders)
18. Medicare Part D Premiums Written (Net of Dividends to Policyholders)
19. Other deductions - A&H (Provide complete documentation)
20 Total Deductions - A&H                                                                                XXXXXX                        XXXXXX

NEW HAMPSHIRE BASIS - TAXABLE PREMIUMS WRITTEN                                          Prem Written    Tax Rate         Tax
21. Net Property & Casualty Premiums Written (L1+L4+L6+L8-L15)                                              1.750%
22. Net Accident & Health Premiums Written   (L2+L5+L7+L9-L20)                                              2.000%
23. Net Taxable Premiums Written                (L21+L22)

COMPUTATION OF BALANCE DUE
24. PREMIUM TAX ON NET PREMIUMS WRITTEN
25. RETALIATORY TAX (L. 24 Col. 4 less L. 24 Col. 3)
26. TOTAL PREMIUM TAX (L.24 Col. 3 plus L.25 Col. 4-MINIMUM $200)
27. OTHER TAXES, FEES, AND ASSESSMENTS (RSA 400-A:35) (Page 2, Line 36)
28. PREMIUM TAX DUE BEFORE BUSINESS TAX CREDITS (BUT NOT LESS THAN $200.00)
29. Business Enterprise Tax Credit (RSA 400-A:34-a)
30. Community Development Financing Authority Credit (RSA 162-L:10)
31. Health Insurance Guaranty Fund Assess (RSA 408-B:13)
32. TOTAL PREMIUM TAXES PAYABLE (L. 28 less sum L. 29-31) NOT LESS THAN ZERO IF $20,000 or more payment by EFT is required
33. PAYMENTS AND CREDITS
     Cash Payments and Credits Applied to Estimated Tax
     Overpayment March 15, 2008 net of refund & fees
     March 15, 2008 Estimated Payment
34. Total Payments and Credits
35. Total Taxes Payable (Overpaid) (Line 32 less Line 34)                                                           1100Z
36. Prepayment Due Mar 15, 2009 (Line 32, MINIMUM $200)                                                             1100Z
37. Filing Fees (Page 2, Col 4, Line 4)                                                                             1347Z
38. Annual License Fee ( Page 2, Col 4, Line 1)                                                                     1104A
39. BALANCE DUE (OVERPAYMENT) MARCH 15, 2009 (LINES 35+36+37+38)

TOTAL AMOUNT PAID




                                                                               PAGE#3
STATE OF DOMICILE
YEAR ENDED DECEMBER 31, 2008
                                                                           DIRECT        DIRECT    DIVIDENDS PAID
                                                                          PREMIUMS      PREMIUMS    OR CREDITED     FINANCE
                                                                           WRITTEN       EARNED        TO PHS       CHARGES
LOB     Premiums written
01.     Fire
02.1    Allied lines
02.2    Multiple peril crop
02.3    Federal Flood
03.     Farmowners multiple peril
04.     Homeowners multiple peril
05.1    Commerical multiple peril (non-liabilty)
05.2    Commerical multiple peril (liabilty)
06.     Mortgage guaranty
08.     Ocean marine
09.     Inland marine
10.     Finanical guaranty
11.     Medical malpractice
12.     Earthquake
13.     Group accident and health
14.     Credit A&H
15.1    Collectively renewable A&H
15.2    Non-cancelable A&H
15.3    Guaranteed renewable A&H
15.4    Non-renewable for stated reasons only
15.5    Other accident only
15.6    Medicare Title XVIII
15.7    All other A&H
15.8    Federal employees health benefits program premium
16.     Workers compensation
17.1    Other liability
17.3    Excess Worker's Compensation
18.     Products liability
19.1    Private passenger auth no-fault (personal injury protection)
19.2    Other private passenger auto liability
19.3    Commercial auto no-fault (personal injury protection)
19.4    Other commercial auto liabilty
21.1    Private passenger auto physical damage
21.2    Commercial auto physical damage
22.     Aircraft (all perils)
23.     Fidelity
24.     Surety
26.     Burglary and theft
27.     Boiler and machinery
28.     Credit
30.     Warranty
34.     Aggregate write-ins for other lines of business
35.     Total premiums written


        Total property & casualty premiums written
        Total accident & health premiums written
        Total premiums written


                                                                                  NH BASIS           STATE OF DOMICILE BASIS
        Other Taxable Consideration - Itemize, provide complete details   PROP & CAS       A&H      PROP & CAS        A&H




        Total Other Considerations


                                                                                  NH BASIS           STATE OF DOMICILE BASIS
        Other Deductions - Itemize, provide complete details              PROP & CAS       A&H      PROP & CAS        A&H




        Total Other Deductions




                                                                           DIRECT        DIRECT    DIVIDENDS PAID
                                                                          PREMIUMS      PREMIUMS    OR CREDITED     FINANCE
                                                                           WRITTEN       EARNED        TO PHS       CHARGES
        Unallocated Premiums Written - P&C (NH Domestics)
        Unallocated Premiums Written - A&H (NH Domestics)




                                                                             ST PAGE

				
DOCUMENT INFO
Description: Medical Malpractice Attorney in New Hampshire document sample