Form INS-5 "Fire Investigation and Prevention Tax Annual Reconciliation/Return" - Maine

What Is Form INS-5?

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

Form Details:

  • Released on December 1, 2020;
  • The latest edition provided by the Maine Department of Administrative and Financial Services;
  • 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 INS-5 by clicking the link below or browse more documents and templates provided by the Maine Department of Administrative and Financial Services.

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FORM INS-5
MAINE REVENUE SERVICES
99
FIRE INVESTIGATION AND PREVENTION TAX
2020
ANNUAL RECONCILIATION / RETURN
*1231100*
MRS Fire Tax Account Number
NAIC ID Number
Period Covered
Due Date
March 15, 2021
January 1 - December 31, 2020
CHECK ALL THAT APPLY:
Business Name (Line 1)
Initial Return
Amended return
Business Name (Line 2)
Final return
Street Address and/or Post Offi ce Box
Enter closing date:
MM DD YYYY
Change of name/address
City
State
ZIP Code
COMPUTATION OF TAX ON FIRE PREMIUMS
1.
Amount of premiums allocated to fi re (See instructions)
A
B
C
D
E
F
Line of Business
Gross Premiums
Dividends Paid
Total Net
Percent of Premiums
Amount of Premiums
(Less Return Premiums
or Credited on
Taxable
Allocated to Fire
Allocated to Fire
and Premiums on
Direct Business
Premiums
(column D x column E)
Policies not Taken)
.00
1a. Fire .........................$
$
$
100.00%
.00
1b. Inland Marine .........$
$
$
26.56%
1c. Aircraft Physical
.00
Damage ..................$
$
$
Actual*
Auto Physical
Damage:
.00
1d. Private Passenger ..$
$
$
2.16%
.00
1e. Commercial ............$
$
$
7.28%
Multiple Peril:
1f. Farmowner’s
.00
Multiple Peril ...........$
$
$
67.05%
1g. Homeowners
.00
Multiple Peril ...........$
$
$
44.11%
1h. Commercial Multiple
.00
Peril (non-liability) ...$
$
$
47.43%
1i. All Other Fire
.00
Related ...................$
$
$
100.00%
.00
2. Total amount of premiums allocated to fi re (Add column F, lines 1a through 1i) ....................................... 2.
.00
3. Tax liability (line 2 multiplied by 1.4% (0.014)) .......................................................................................... 3.
.00
4. Estimated payments .................................................................................................................................. 4.
.00
5. Balance due (If line 3 is greater than line 4, line 3 minus line 4) ............................................................... 5.
.00
6. Overpayment to be refunded (If line 4 is greater than line 3, line 4 minus line 3) ..................................... 6.
* Line 1c only: Enter in column F the premiums actually received on fi re risks located in Maine.
Revised: December 2020
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FORM INS-5
MAINE REVENUE SERVICES
99
FIRE INVESTIGATION AND PREVENTION TAX
2020
ANNUAL RECONCILIATION / RETURN
*1231100*
MRS Fire Tax Account Number
NAIC ID Number
Period Covered
Due Date
March 15, 2021
January 1 - December 31, 2020
CHECK ALL THAT APPLY:
Business Name (Line 1)
Initial Return
Amended return
Business Name (Line 2)
Final return
Street Address and/or Post Offi ce Box
Enter closing date:
MM DD YYYY
Change of name/address
City
State
ZIP Code
COMPUTATION OF TAX ON FIRE PREMIUMS
1.
Amount of premiums allocated to fi re (See instructions)
A
B
C
D
E
F
Line of Business
Gross Premiums
Dividends Paid
Total Net
Percent of Premiums
Amount of Premiums
(Less Return Premiums
or Credited on
Taxable
Allocated to Fire
Allocated to Fire
and Premiums on
Direct Business
Premiums
(column D x column E)
Policies not Taken)
.00
1a. Fire .........................$
$
$
100.00%
.00
1b. Inland Marine .........$
$
$
26.56%
1c. Aircraft Physical
.00
Damage ..................$
$
$
Actual*
Auto Physical
Damage:
.00
1d. Private Passenger ..$
$
$
2.16%
.00
1e. Commercial ............$
$
$
7.28%
Multiple Peril:
1f. Farmowner’s
.00
Multiple Peril ...........$
$
$
67.05%
1g. Homeowners
.00
Multiple Peril ...........$
$
$
44.11%
1h. Commercial Multiple
.00
Peril (non-liability) ...$
$
$
47.43%
1i. All Other Fire
.00
Related ...................$
$
$
100.00%
.00
2. Total amount of premiums allocated to fi re (Add column F, lines 1a through 1i) ....................................... 2.
.00
3. Tax liability (line 2 multiplied by 1.4% (0.014)) .......................................................................................... 3.
.00
4. Estimated payments .................................................................................................................................. 4.
.00
5. Balance due (If line 3 is greater than line 4, line 3 minus line 4) ............................................................... 5.
.00
6. Overpayment to be refunded (If line 4 is greater than line 3, line 4 minus line 3) ..................................... 6.
* Line 1c only: Enter in column F the premiums actually received on fi re risks located in Maine.
Revised: December 2020
99
2020 Form INS-5, Page 2
*1231101*
MRS Fire Tax Account Number:
AFFIDAVIT AND SIGNATURE
This return is made in compliance with the provisions of 25 M.R.S. § 2399. The amount of all gross direct premiums or assessments for fi re risks
written by this insurer on risks located in, or received from risks resident of, the State of Maine during the year ending December 31, 2020 has been
reported. Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my
knowledge and belief, they are true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer
has any knowledge.
Date:
Signature:
Telephone #:
Must be signed by the President, Treasurer, Secretary, Chief Accounting Offi cer or Attorney-in-fact of a reciprocal insurer.
Preparer’s
Date:
Signature:
ID Number:
INSTRUCTIONS
Premium amounts to be reported: A premium is an amount
losses based on historical data. An insurer may not deviate
paid or payable for an insurance policy, including all fees (except
from these percentages.
provider fees paid for service contracts), such as membership,
Column F Amount of Premiums Allocated to Fire. Multiply
policy, survey, inspection, service and finance fees, that are
the column D amount by the column E percentage and enter
assessed by and paid to an insurance company in consideration
the result.
for an insurance policy. The instructions below provide guidance
to assist in the preparation of this return. However, accurate and
Line 2. Total Premium. Add column F amounts for each line of
full reporting of premium amounts, including any applicable fees,
business (line 1a through line 1i) and enter the sum on this line
is the responsibility of each taxpayer.
(Total amount of premiums allocated to fi re).
Note: The fi re investigation and prevention tax applies in addition
Line 3. Tax Liability. Every fi re insurance company or association
to the insurance premiums tax. A fraternal benefi t society, order, or
that does business or collects premiums or assessments in Maine
lodge, as defi ned in 24-A M.R.S. section 4101(1) is exempt from
is required by statute to pay 1.4% of the net taxable premiums for
Maine insurance premiums taxes.
fi re risks written in Maine.
Line 1. Amount of Premiums Allocated to Fire. Calculate the
Line 4. Estimated Payments. Enter the total amount of monthly
total amount of premiums allocated to fi re insurance for each line
estimated payments already made in 2020.
of business identifi ed in column A.
Line 5. Balance Due. Payment is due with this return. Late
Column B Gross Premiums. Enter the gross direct premiums
payments are subject to interest and penalties.
written, less return premiums and premiums on policies not
taken. Generally, gross direct premiums are reported on the
Note: Taxpayers with annual tax liabilities of $10,000 or more
Exhibit of Premiums and Losses (Maine State Page) of the
are required to remit tax payments electronically. See MRS
NAIC Annual Statement, column 1 and related fi nance and
Rule 102 on the MRS website at www.maine.gov/revenue/
service charges are reported on Schedule T, column 8 (Finance
publications/rules for details.
and Service Charges not Included in Premiums).
For calendar year 2021, the interest rate is 5%, compounded
Column C Dividends Paid or Credited on Direct Business.
monthly. The penalty for failure to fi le a return is the greater
Enter dividends paid or credited to policyholders on direct
of $25 or 10% of the tax due. If the return is not fi led within 60
premiums. Amounts entered must agree with column 3 of the
days after the receipt of a demand notice to fi le, the penalty is
Maine portion of the NAIC annual statement.
the greater of $25 or 25% of the tax due. The penalty for failure
to pay a tax liability on time is 1%, up to a maximum of 25%, of
Column D Total Net Taxable Premiums. Subtract the column
the outstanding liability.
C amount from the column B amount and enter the result.
Line 6. Overpayment. All overpayments will be refunded.
Column E Percent of Premiums Allocated to Fire. The
percentages listed represent the ratio of fi re losses to total
If enclosing a check, make check payable to:
If not enclosing a check,
Treasurer, State of Maine
and MAIL WITH RETURN TO:
MAIL RETURN TO:
MAINE REVENUE SERVICES
MAINE REVENUE SERVICES
P.O. BOX 1065
P.O. BOX 1064
AUGUSTA, ME 04332-1065
AUGUSTA, ME 04332-1064
Physical location (for delivery service only): Maine Revenue Services, 51 Commerce Drive, Augusta, ME 04330
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