Form RCT-121A "Gross Premiums Tax - Domestic Casualty, Fire or Life Insurance Companies" - Pennsylvania

What Is Form RCT-121A?

This is a legal form that was released by the Pennsylvania Department of Revenue - a government authority operating within Pennsylvania. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2019;
  • The latest edition provided by the Pennsylvania Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form RCT-121A by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Revenue.

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Download Form RCT-121A "Gross Premiums Tax - Domestic Casualty, Fire or Life Insurance Companies" - Pennsylvania

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FILL IN FORM USING ALL CAPS.DO NOT USE DASHES (-) OR SLASHES (/) IN ANY FIELD. ENTER DATES AS MMDDYYYY. USE WHOLE DOLLARS ONLY.
1211018105
OFFICIAL USE ONLY
rct-121A
Date Received (Official Use Only)
PAgE 1 Of 3
01-19
grOSS PrEmIUmS tAX - DOmEStIc cASUAlty,
c
fIrE Or lIfE InSUrAncE cOmPAnIES
Tax Year Begin:
START
Revenue ID
Federal ID (FEIN)
Parent Corporation (FEIN)
Tax Year End:
12/31/20
_ _
Due Date: April 15
Please select correct letter in drop down
Taxpayer Name
Check to Indicate a Change of Address
Send All Correspondence to the Preparer
First Line of Address
Amended Report (Include REV-1175.)
First Report
Second Line of Address
Payment Made Electronically
PLHIGA/KOZ/EIP
City
State
ZIP
As Originally Registered with PA Dept. of
Insurance: Domestic Casualty = A
Phone
Domestic Fire = B
Domestic Life = C
Email
Final Report (See Instructions.)
Out of Existence Date:
USE whOlE DOllArS Only
1a. Domestic Casualty Gross Premiums Tax (Page 2, Line 15)
1a.
1b. Domestic Fire Gross Premiums Tax (Page 2, Line 15)
1b.
1c. Domestic Life Gross Premiums Tax (Page 2, Line 15)
1c.
1d. Total Insurance Premiums Tax Liability (Line 1a plus Line 1b plus Line 1c)
1d.
2.
Total Estimated Payments
2.
3.
Total Payments Carried Forward From Prior Year Return
3.
4.
Total “Restricted” Tax Credits
4.
5.
Total Credit: (Line 2 plus Line 3 plus Line 4)
5.
6.
Tax Due: (If Line 1d is more than Line 5, enter the difference here.)
6.
7.
Remittance
7.
8.
Overpayment: (If Line 5 is more than Line 1d, enter the difference here.)
8.
9.
Refund: (Amount of Line 8 to be refunded after offsetting all unpaid liabilities)
9.
10. Transfer: (Amount of Line 8 to be credited to the next tax year after offsetting
10.
all unpaid liabilities)
1211018105
corporate Officer Information:
Social Security
Number of Officer
Officer Last Name
Officer First Name
Phone
Title of Officer
Email
I affirm under penalties prescribed by law, this report, including any accompanying schedules and statements, has been examined by me and to the best of my
knowledge and belief is a true, correct and complete report. If this report is an amended report, the taxpayer hereby consents to the extension of the assessment
period for this tax year to one year from the date of filing of this amended report or three years from the filing of the original report, whichever period last expires,
and agrees to retain all required records pertaining to that tax and tax period until the end of the extended assessment period, regardless of any statutory
provision providing for a shorter period of retention. For purposes of this extension, an original report filed before the due date is deemed filed on the due date.
I am authorized to execute this consent to the extension of the assessment period.
Signature of Officer
Date
Signature of Officer – Please sign after printing
Reset Entire Form
RETURN TO TOP
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PRINT FORM
FILL IN FORM USING ALL CAPS.DO NOT USE DASHES (-) OR SLASHES (/) IN ANY FIELD. ENTER DATES AS MMDDYYYY. USE WHOLE DOLLARS ONLY.
1211018105
OFFICIAL USE ONLY
rct-121A
Date Received (Official Use Only)
PAgE 1 Of 3
01-19
grOSS PrEmIUmS tAX - DOmEStIc cASUAlty,
c
fIrE Or lIfE InSUrAncE cOmPAnIES
Tax Year Begin:
START
Revenue ID
Federal ID (FEIN)
Parent Corporation (FEIN)
Tax Year End:
12/31/20
_ _
Due Date: April 15
Please select correct letter in drop down
Taxpayer Name
Check to Indicate a Change of Address
Send All Correspondence to the Preparer
First Line of Address
Amended Report (Include REV-1175.)
First Report
Second Line of Address
Payment Made Electronically
PLHIGA/KOZ/EIP
City
State
ZIP
As Originally Registered with PA Dept. of
Insurance: Domestic Casualty = A
Phone
Domestic Fire = B
Domestic Life = C
Email
Final Report (See Instructions.)
Out of Existence Date:
USE whOlE DOllArS Only
1a. Domestic Casualty Gross Premiums Tax (Page 2, Line 15)
1a.
1b. Domestic Fire Gross Premiums Tax (Page 2, Line 15)
1b.
1c. Domestic Life Gross Premiums Tax (Page 2, Line 15)
1c.
1d. Total Insurance Premiums Tax Liability (Line 1a plus Line 1b plus Line 1c)
1d.
2.
Total Estimated Payments
2.
3.
Total Payments Carried Forward From Prior Year Return
3.
4.
Total “Restricted” Tax Credits
4.
5.
Total Credit: (Line 2 plus Line 3 plus Line 4)
5.
6.
Tax Due: (If Line 1d is more than Line 5, enter the difference here.)
6.
7.
Remittance
7.
8.
Overpayment: (If Line 5 is more than Line 1d, enter the difference here.)
8.
9.
Refund: (Amount of Line 8 to be refunded after offsetting all unpaid liabilities)
9.
10. Transfer: (Amount of Line 8 to be credited to the next tax year after offsetting
10.
all unpaid liabilities)
1211018105
corporate Officer Information:
Social Security
Number of Officer
Officer Last Name
Officer First Name
Phone
Title of Officer
Email
I affirm under penalties prescribed by law, this report, including any accompanying schedules and statements, has been examined by me and to the best of my
knowledge and belief is a true, correct and complete report. If this report is an amended report, the taxpayer hereby consents to the extension of the assessment
period for this tax year to one year from the date of filing of this amended report or three years from the filing of the original report, whichever period last expires,
and agrees to retain all required records pertaining to that tax and tax period until the end of the extended assessment period, regardless of any statutory
provision providing for a shorter period of retention. For purposes of this extension, an original report filed before the due date is deemed filed on the due date.
I am authorized to execute this consent to the extension of the assessment period.
Signature of Officer
Date
Signature of Officer – Please sign after printing
Reset Entire Form
RETURN TO TOP
NEXT PAGE
PRINT FORM
FILL IN FORM USING ALL CAPS.DO NOT USE DASHES (-) OR SLASHES (/) IN ANY FIELD. ENTER DATES AS MMDDYYYY. USE WHOLE DOLLARS ONLY.
1211018205
Revenue ID
rct-121A
PAgE 2 Of 3
01-19
AttAch A cOPy Of thE PEnnSylVAnIA BUSInESS PAgE AnD SchEDUlE t Of
thE AnnUAl rEPOrt fIlED wIth thE PEnnSylVAnIA InSUrAncE DEPArtmEnt
c
USE whOlE DOllArS Only
casualty and fire Insurance
1.
Gross Direct Premiums Received less Cancellations and Premiums Returned
1.
2.
Extraordinary Medical Benefit Premiums (Include footnote, see instructions.)
2.
3.
Dividends to Policy Holders
3.
4.
Other Deductions (Attach Schedule.)
4.
5.
Taxable Fire and Casualty Premiums (Line 1 minus Lines 2, 3 and 4)
5.
life Insurance
6.
Gross Life Premiums (Direct Written Basis)
6.
7.
Dividends to Policy Holders
7.
8.
Other Deductions (Attach Schedule.)
8.
9.
Taxable Life Premiums (Line 6 minus Lines 7 and 8)
9.
Accident and health Insurance
10. Gross Direct Accident and Health Premiums
10.
11. Dividends to Policy Holders
11.
12. Other Deductions (Attach Schedule.)
12.
13. Taxable Accident and Health Premiums (Line 10 minus Lines 11 and 12)
13.
14. Total Taxable Premiums (Add Lines 5, 9 and 13)
14.
15. Tax (Line 14 times tax rate - See Instructions.)
15.
If registered with the PA Department of Insurance as a casualty Insurance company, enter line 15 on Page 1, line 1a. If registered with the
PA Department of Insurance as a fire Insurance company, enter line 15 on Page 1, line 1b. If registered with the PA Department of Insurance
as a life Insurance company, enter line 15 on Page 1, line 1c.
16. State of Domicile
16.
17. NAIC Number
17.
1211018205
Preparer’s Information:
Firm Name
Individual Preparer Name
Firm FEIN
Phone
Address
Email
City
Social Security Number
or PTIN
State
ZIP
I affirm under penalties prescribed by law, this report, including any accompanying schedules and statements, has been prepared by me and to the best of
my knowledge and belief is a true, correct and complete report.
Signature of Preparer
Date
Signature of Preparer – Please sign after printing
Reset Entire Form
RETURN TO PAGE 1
NEXT PAGE
PRINT FORM
FILL IN FORM USING ALL CAPS.DO NOT USE DASHES (-) OR SLASHES (/) IN ANY FIELD. ENTER DATES AS MMDDYYYY. USE WHOLE DOLLARS ONLY.
1211018305
Revenue ID
rct-121A
PAgE 3 Of 3
01-19
rct-121A PlhIgA cAlcUlAtIOn wOrKShEEt
Schedule of guaranteed Premiums
Accident & Health
Life
Annuity
Guaranteed
*
Non-Guaranteed
Total
guaranteed Premiums are those premiums in which the premium rates are guaranteed during the continuance of the respective policies without a
right exercisable by the company to increase said premium rates. 40 P.S. § 991.1711(b)
*All Annuity premiums are treated as guaranteed premiums.
PlhIgA credit calculation
Assessment Date & Amount
Accident & Health Amount
Life Amount
Annuity Amount
Total of Assessments
Guaranteed Premiums
Total Premiums
Percentage of Qualified Premiums =
Total Credits Allowed
Total of Assessment
Percentage of Qualified Premiums
Total Credit Allowed
X
=
Accident & Health
X
=
Life
X
=
Annuity
100%
X
=
Total all Class-A
100%
Administrative Assessments
X
=
tOtAl
total credit Allowed Per year
Total Credit Allowed
X
20%
=
Total Credit Per Year (Limited to 2% Tax)
X
20%
=
In order to claim a credit, you must complete the above calculations AnD include a copy of the assessment summary, assessment detail,
copy of the cancelled check paying the assessment and PA Business Page and Schedule t for the year immediately preceding the year of
the assessment. failure to complete the worksheet will result in the denial of the credit.
1211018305
1211018305
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