Form 207Insurance Premiums Tax Return

Domestic Companies

1. Grossdirectpremiumsreceivedduringthecalendaryear:Seeinstructions.................................................. 1 00

2. Dividendspaid:Seeinstructions..................................................................................................................... 2 00

3. Taxablepremiums:SubtractLine2fromLine1.............................................................................................. 3 00

4. Tax:MultiplyLine3by1.75%(.0175)............................................................................................................. 4 00

5. EnteramountfromFormCT-207K,Part4,Line31,ColumnC....................................................................... 5 00

6. EnteryourCIGAassessmentcredit.Seeinstructions..................................................................................... 6 00

7. EnteryourCLHIGAassessmentcredit.Seeinstructions................................................................................ 7 00

8. AddLines5,6,and7....................................................................................................................................... 8 00

9. Nettax:SubtractLine8fromLine4. Iflessthanzero,enterzero“0.”........................................................... 9 00

10. Overpaymentappliedfromprioryear.............................................................................................................. 10 00

11. PaymentsmadewithestimatedtaxpaymentcouponsForms 207 ESA, ESB, ESC, and ESD .................... 11 00

12. PaymentsmadewithextensionrequestForm 207/207 HCC EXT................................................................. 12 00

13. Totalpriorpayments:AddLines10,11,and12.............................................................................................. 13 00

14. IfLine13isgreaterthanLine9,enteramountoverpaid................................................................................. 14 00

15. Amounttobe:creditedto2012estimatedtax(15a)$_____________refunded(15b)$______________ 15 00 For faster refund, use Direct Deposit by completing Lines 15c, 15d, and 15e.15c. Checking Savings 15d. Routingnumber

15e. Accountnumber 15f.WillthisrefundgotoabankaccountoutsidetheU.S.?Yes

16. IfLine9isgreaterthanLine13,enteramountowed...................................................................................... 16 00

17. Iflate:penalty(17a)$__________________ plusinterest(17b)$__________________ Seeinstructions. 17 00

18. Interestonunderpaymentofestimatedtax:Attach Form 207I.Seeinstructions........................................... 18 00

19. Balanceduewiththisreturn.MakecheckpayabletoCommissioner of Revenue Services....................... 19 00

Declaration:IdeclareunderpenaltyoflawthatIhaveexaminedthisreturn(includinganyaccompanyingschedulesandstatements)and,tothebestofmyknowledgeandbelief,itistrue,complete,andcorrect.IunderstandthepenaltyforwillfullydeliveringafalsereturnordocumenttoDRSisafineofnotmorethan$5,000,imprisonmentfornotmorethanfiveyears,orboth.Thedeclarationofapaidpreparerotherthanthetaxpayerisbasedonallinformationofwhichthepreparerhasanyknowledge.

Signatureofprincipalofficer Title DatePrintnameofprincipalofficer Telephonenumber ()Paidpreparer’ssignature Date Preparer’sSSNorPTIN

Firmnameandaddress FEIN

Sign Here

Keepacopyofthisreturnforyourrecords.

VisittheDepartmentofRevenueServices(DRS)websiteatwww.ct.gov/TSCtopayelectronically.

Nameofcompany ConnecticutTaxRegistrationNumber

AddressNumberandstreet POBox Datereceived(DRSuseonly)

Cityortown State ZIPcode FederalEmployerIDNumber(FEIN)

Taxpayer

Pleasetype

orprint.

DepartmentofRevenueServicesStateofConnecticutPOBox2990HartfordCT06104-2990(Rev.12/11)

2011Completethisreturninblueorblackinkonly.

Entersurvivor’sCTTaxRegistrationNo.

General InformationA. Checkifthisisanamendedreturn.B. Changeof: Address Domicile,enternewdomicile:________________________________________________________________ C. Ifthisisashortperiod,enterperiodcoveredbythisreturn:________________________________________________________________________ D. Ifthisisafinalreturn,istheinsurancecompany:NolongerlicensedinConnecticut;outofbusiness Merged/reorganized ______________________________________________________

E. Theinsurancecompanyiscurrentlyin: Receivership Rehabilitation

Form 207 Instructions

Form207Back(Rev.12/11)

General InstructionsCompletethisreturninblueorblackinkonly.Due Date:ThisreturnisdueonorbeforeMarch1,2012,forinsurancepremiumstaxliabilityforcalendaryear2011.Attachments:Attachthefollowingtothisreturn:• AcopyofScheduleT;• ConnecticutbusinesspagefromtheAnnualStatementfiledwiththe

ConnecticutInsuranceDepartment;• 2011ScheduleGAA,ifapplicable;• 2011Form207I,ifapplicable;• 2011FormCT-207K,ifapplicable.Rounding Off to Whole Dollars:Youmustroundoffcentstothenearestwhole dollar on your return and schedules. If you do not round, theDepartmentofRevenueServices(DRS)willdisregardthecents.Round down to the next lowest dollar all amounts that include1through49cents.Rounduptothenexthighestdollarallamountsthatinclude50through99cents.However,ifyouneedtoaddtwoormoreamountstocomputetheamounttoenteronaline,includecentsandroundoffonlythetotal.Example:Addtwoamounts($1.29+$3.21)tocomputethetotal($4.50)toenteronaline.Round$4.50to$5.00andenter$5.00ontheline.Filing an Amended Return: Ifyoumakeanerror(s)onyourreturn,youmustcorrecttheerror(s)byfilinganamendedreturnusinganewForm207andcheckingtheamendedboxatthetopofthereturn.CompleteForm207usingthecorrectfiguresandinformationforthereportingperiod.Youmust file anamended return claiminga refundor credit of a taxoverpaymentwithinthreeyearsoftheduedateforwhichtheoverpaymentwasmade.Attachanexplanationoftheclaimtotheamendedreturn.

Line InstructionsLine 1: Enter grossdirect premiums (less return premiums, includingcancellations)receivedduringthecalendaryearfrompolicieswrittenonpropertyorriskslocatedorresidentinthisstate,butexcludingannuityconsiderations andpremiums received for reinsuranceassumed fromothercompanies.Line 2:Enterdividendspaidtopolicyholdersondirectbusiness.Donotincludeanydividendspaidonaccountoftheownershipofstock.Line 5:IfyourcompanyisclaimingConnecticuttaxcredits,FormCT-207K,Insurance/Health Care Tax Credit Schedule,must be completed andattachedtothisreturn.Line 6 and Line 7: ToclaimCIGAandCLHIGAassessmentcredits,youmustcompleteandattacha2011ScheduleGAA, Insurance Guaranty Association Credit.Line 10:Enterprioryearoverpayment(s).Line 11:EnterestimatedpaymentsmadewithForms207ESA,ESB,ESC,andESD,Estimated Insurance Premiums Tax Payment Coupon Domestic Insurance Companies.Line 12: EnterpaymentmadewithForm207/207HCCEXT,Application for Extension of Time to File Domestic Insurance Premiums Tax Return or Health Care Center Tax Return.TorequestanextensionoftimetofileForm207,acompanymustfileForm207/207HCCEXTandpayallthetaxitexpectstooweonorbeforeMarch1,2012.Line 14:IfLine13isgreaterthanLine9,subtractLine9fromLine13.Thisistheamountyouoverpaid.Line 15a:Entertheamountofoverpaymentyouwantcreditedtoyour2012estimatedinsurancepremiumstax.Youroverpaymentwillbecreditedtoyour2012estimatedinsurancepremiumstaxasofMarch1,2012,orthedatethatthisreturnisfiled,whicheverislater.Therefore,ifthisreturnisfiledafterMarch15,2012,yourestimatedinsurancepremiumstaxpaymentforMarch15,2012,willnotbetimelymade.Line 15b:Entertheamountofoverpaymentyouwantrefundedtoyou.Line 15: Add Line 15a and Line 15b.Your election to credit your overpayment to your 2012 estimated insurance premiums tax or to have your overpayment refunded to you is irrevocable.

Lines 15c through 15e:Getyourrefundfasterbychoosingdirect deposit.CompleteLines15c,15d,and15etohaveyourrefunddirectlydepositedintoyourcheckingorsavingsaccount.

Enteryournine-digitbankroutingnumberandyourbankaccountnumberinLines15dand15e.Yourbankroutingnumberisthefirstnine-digitnumberprinted on your check or savingswithdrawal slip.Your bank accountnumbergenerally follows thebankroutingnumber.Donot include thechecknumberaspartofyouraccountnumber.Bankaccountnumberscanbeupto17digitsandmustbenumeric.Ifanyofthebankinformationyousupplyfordirectdepositdoesnotmatchoryouclosetheapplicablebankaccountpriortothedepositoftherefund,yourrefundwillautomaticallybemailed.Line 15f:FederalbankingrulesrequireDRStorequestinformationaboutforeignbankaccountswhenthetaxpayerrequeststhedirectdepositofarefundintoabankaccount.IftherefundistobedepositedinabankoutsideoftheUnitedStates,DRSwillmailtherefund.Line 16: If Line 9 is greater than Line 13, subtract Line 13 fromLine9.Thisistheamountoftaxyouowe.Line 17a:LatePaymentPenalty:MultiplyLine16by10%.Entertheresultor$50,whicheverisgreater.Line 17b:MultiplyLine16by1%permonthorfractionofamonthfromtheoriginalduedateofthereturntothedateofpayment.Line 18:Ifestimatedtaxwasunderpaid,completeandattachForm207I,Underpayment of Estimated Insurance Premiums Tax or Health Care Center Tax,andentertheamountfromLine22ofForm207I.Line 19:AddLines16,17,and18.MakecheckpayabletoCommissionerofRevenueServices.Write“2011Form207”andyourConnecticutTaxRegistrationNumberonthefrontofyourcheck.DRSmaysubmityourchecktoyourbankelectronically.Mailto: DepartmentofRevenueServices StateofConnecticut POBox2990 HartfordCT06104-2990Signature:Thetreasurerofthecompany,oranauthorizedagentorofficerofthecompany,mustsignForm207.Paid Preparer Signature: A paid preparer must sign and dateForm207.PaidpreparersmustalsoentertheirSocialSecurityNumber(SSN)orPreparerTaxIdentificationNumber(PTIN)andtheirfirm’sFederalEmployerIDNumber(FEIN)inthespacesprovided.

Pay ElectronicallyVisitwww.ct.gov/TSC tomakeadirect taxpayment.Using this option authorizesDRS to electronicallywithdrawapaymentfromyourbankaccount(checkingorsavings)onadateyouselectuptotheduedate.Ifyoupayelectronically,youmuststillfileyourreturnonorbeforetheduedate.

For More InformationCallDRSduringbusinesshours,MondaythroughFriday:• 1-800-382-9463(ConnecticutcallsoutsidetheGreaterHartford

callingareaonly),or• 860-297-5962(fromanywhere).TTY,TDD, and Text Telephone users onlymaytransmitinquiriesanytimebycalling860-297-4911.Forms and PublicationsVisit the DRSwebsite atwww.ct.gov/DRS to download and printConnecticuttaxformsandpublications.

Routing Number

Name of Depositor Street Address City, State, Zip CodePay to the Order of

No. 101

Name of your BankStreet AddressCity, State, Zip Code

092125789 091 025 025413 0101

$

Date

Account Number