Form 63-29A Ocean Marine Profits Tax Return

Form 63-29A Ocean Marine Profits Tax Return 2001 Massachusetts Department of Revenue To be file by omestic an foreign insurance companies which are subject to the provisions of Massachusetts General Laws, Ch. 63, section 29A. For calenar year 2001 or taxable year beginning 2001 an ening Name of company Feeral Ientification number Mailing aress Department of Revenue use only Name of treasurer Organize uner the laws of Has the feeral government change your taxable income for any prior year which has not yet been reporte to Massachusetts? Yes No. All amounts must be properly entere on all forms. Failure will result in a penalty assessment. Attachments are not sufficient compliance. Uner the penalties of perjury, I eclare that I have examine this return, incluing accompanying scheules an statements, an to the best of my knowlege an belief, it is true, correct an complete. Declaration of preparer (other than taxpayer) is base on all information of which he/she has knowlege. Signature of appropriate corporate officer Social Security number Telephone number Date Iniviual or firm signature of preparer Employer Ientification number Aress Date ❿ If you are signing as an authorize elegate of the appropriate corporate officer, check here an attach Mass. Form M-2848, Power of Attorney. General Instructions Where marine premiums are calle for in this return, only premiums on goos or other insurable interests in the course of exportation, importation or transportation coastwise, or upon these goos or insurable interests while being prepare for or awaiting such shipment are to be inclue. The Massachusetts marine premiums not inclue in the foregoing classification are not subject to the provisions of sec. 29A of Ch. 63 of the Massachusetts General Laws but may be taxable uner sec. 22 (omestic company) or sec. 23 (foreign company). All companies which reasonably estimate their insurance excise to be in excess of $1,000 are require to pay quarterly 40%, 25%, 25% an 10% of the tax ue. See Form 355-ES which will be maile to such companies. Failure to receive such forms, however, will not excuse any subject company from making the require payments of estimate tax. Any inquiries relative to the filing of estimate tax vouchers or payments with respect thereto shoul be aresse to the Massachusetts Department of Revenue, Banking an Insurance Unit, PO Box 7052, Boston, MA 02204. The actual estimate tax payments mae must agree with the estimate tax payments shown on each return. All returns file are on account of separate an istinct taxes, an payments mae on account thereof shoul be so treate. An overpayment of one tax may not be taken as a creit against the current year s liability of another tax. Full Employment Program Creit. A qualifie employer participating in the Full Employment Program may claim a creit of $100 per month of eligible employment per employee. The maximum amount of creit that may be applie in all taxable years with respect to each employee is $1,200. Enter the amount of Full Employment Creit claime this year from Scheule FEC, line 21. Attach Scheule FEC to this return. For more information, contact the Department of Transitional Assistance, 600 Washington Street, Boston, MA 02111. Any corporation that wishes to contribute any amount to the Natural Heritage an Enangere Species Fun may o so on this form. This amount is ae to the excise ue. It increases the amount of the corporation s payment or reuces the amount of its refun. The Natural Heritage an Enangere Species Fun is aministere by the Department of Fisheries, Willife an Environmental Law Enforcement to provie for conservation programs for rare, enangere an nongame willife an plants in the Commonwealth. Reprouction of returns must be approve by DOR prior to filing an meet the criteria provie in Technical Information Release 95-8. Please aress forms approval to The Banking & Insurance Unit, PO Box 7052, Boston, MA 02204. This return, together with payment in full, is ue on or before May 15, 2002. Any portion of this excise not pai by the ue ate bears interest at the applicable rate, an a penalty of ¹ ₂% per month, up to a maximum of 25%. Failure to file this return on time incurs a penalty of 1% per month (or fraction thereof), up to a maximum of 25% of the tax ue. Mail to: Massachusetts Department of Revenue, PO Box 7052, Boston, MA 02204. Make check or money orer payable to: Commonwealth of Massachusetts. Form coe 374 Tax type 0121

Scheule Supporting Divien Deuction on page 3 in line 8 Diviens pai or creite to policyholers uring the taxable year 2001. Unite States marine business subject to Section 29A of Chapter 63. a On irect business.................................................................................... a $ 2001 63-29A Page 2 b c e On reinsurance assume............................................................................... b Total............................................................................................... c Less iviens receive on reinsurance pai............................................................... Net iviens pai or creite uring 2001 on U.S. 29A Marine (page 3, line 8)..................................... e Scheule Supporting Feeral Income Tax Deuction in line 9A on Page 3 f Total amount of feeral income tax (actual) on business year 2001............................................... f Give ate for filing feeral return In support of line f, furnish a copy of your U.S. Corporation Income Tax Return, Form 1120. State the amount of unerwriting gain an of investment income that comprise Taxable Income in line 30 of sai return. If above ate inicates feeral return is not yet file, state that line f is estimate. Submit aforementione copy when available an the recomputation of lines f to m if necessary. Part of (f) covering g Investment income.................................................................................... g Total tax on Normal Tax or Normal & Surtax Excess Profits Tax h Unerwriting gain.......... $..... $..... $ h j Unerwriting profit All classes (Insurance Expense Exhibit, Part II)............................................. j k Unerwriting profit Unite States 29A Marine from page 3, line 9.............................................. k Unerwriting profit Unite States 29A Marine, item K l Ratio............................................................................................ l % Unerwriting profit all classes, item j m Feeral income tax on U.S. 29A Marine Business of year 2001 obtain as follows:................................ m If ratio in line l is less than 100%, apply sai ratio to item h. If ratio in line l excees 100%, the following ratio is to be applie to item h: Unerwriting profit Unite States 29A Marine, item k Sum of unerwriting gains of all classes showing gains in Expense Exhibit. Part II Complete the following scheule. The ocean marine unerwriting profit as reporte in the insurance expense exhibit is to be allocate to alien an Unite States with no ajustment in the latter for exclusion of prior losses. Give percentages that losses incurre an expenses incurre bear to earne premiums. Ocean Marine Unerwriting Profit per Expense Exhibit Alien Unite States Net earne premiums........... $ % $ $ % $ Net losses incurre............. Net expenses incurre........... Unerwriting profit.............. Alien Unite States

Scheule of Profit on Marine Insurance Written in the Unite States During the Year Ene December 31, 2001 (Taxable year) in Accorance with the Provisions of Section 29A of Chapter 63 of the General Laws of the Commonwealth of Massachusetts Line 11 Net premiums on marine insurance written in the Unite States uring the taxable year, meaning gross premiums less return premiums, premiums on policies not taken an net premiums pai for reinsurance (line 40, column 4)................................................................... 1 $ 12 Deuct: Unearne premiums on such marine insurance at en of taxable year.................................... 2 13 Total.............................................................................................. 3 14 A: Unearne premiums on such marine insurance at the beginning of year..................................... 4 15 Net earne premiums on Unite States 29A marine insurance for taxable year.................................... 5 16 Deuct: Net losses incurre (line 61)............................... 6 $ 17 Deuct: Net expenses incurre (line 51)............................ 7 18 Deuct: Diviens pai or creite to policyholers (item e)............. 8 19 Balance........................................................................................... 9 19a Deuct: Feeral income tax (item m).................................................................... 9a 10 Balance.......................................................................................... 10 10a A excess of sum of lines 7 an 9a over 40% of net premiums (line 1)....................................... 10a 11 Net unerwriting profit on Unite States 29A Marine taxable year 2001......................................... 11 Calculation of Tax 12a Net unerwriting profit for the year ene December 31, 2001 (line 11)........................................ 12a 2001 63-29A Page 3 12b Net unerwriting profit for the year ene December 31, 2000............................................... 12b 12c Net unerwriting profit for the year ene December 31, 1999............................................... 12c 13 Total for 3-year perio............................................................................... 13 14 Average net unerwriting profit (¹ ₃ of line 13)............................................................. 14 15 Ratio average Massachusetts marine premiums average Unite States marine premiums percentage obtaine in line 72.............................. 15 % 16 Amount taxable (apply percentage line 15 to line 14)..................................................... ❿ 16 17 Tax at 5.7%....................................................................................... 17 18 Economic Opportunity Area Recapture (attach Scheule H-2).............................................. ❿ 18 19 Tax ue before creits. A lines 17 an 18............................................................ ❿ 19 20 Economic Opportunity Area Creit (Scheule EOA, line 9)................................................. ❿ 20 Note: If you claime the EOA creit on Form 63-22 or Form 63-23, you cannot claim it on this form. 21 Full Employment Creit (Scheule FEC)............................................................... ❿ 21 Note: If you claime the FEC on Form 63-22 or Form 63-23, you cannot claim it on this form. 22 Excise ue before voluntary contribution. Subtract the total of line 20 an line 21 from line 19. Not less than 0.......... 22 23 Voluntary contribution for enangere willife conservation................................................ ❿ 23 24 Excise ue plus voluntary contribution. A lines 22 an 23................................................ ❿ 24 25 2000 overpayment applie to 2001 estimate tax.................. ❿ 25 26 2001 Massachusetts estimate tax payments (o not inclue amount from line 25)............................ ❿ 26 27 Payments mae with extension................................ ❿ 27 28 Total payments. A lines 25 through 27................................................................. 28 29 If total in line 28 is larger than line 24, enter amount overpai................................................. 29 30 Amount of line 29 to be creite to 2002 estimate tax.............. ❿ 30 31 Amount of line 29 to be refune. Subtract line 30 from line 29............................................. ❿ 31 32 If line 24 is larger than the total in line 28, enter the balance ue.............................................. 32 33 M-2220 penalty ❿!$ ; Other penalties ❿!$ Total penalty................ 33 34 Interest on unpai balance.......................................................................... ❿ 34 35 Total payment ue at time of filing.................................................................... ❿ 35

Supplementary Scheule 1 Entire 2 Foreign 3 Business business all classes line 40(c) Unite St Premiums Written all classes ocean marine an 45() all class all others (col. 1 minus to 36 Direct (net of refune).......................................... 36 37 Reinsurance assume (net of returne)............................. 37 38 Total (sum of lines 36 an 37)..................................... 38 39 Deuct: Reinsurance premiums cee.............................. 39 40 Net premiums retaine.......................................... 40 c Losses Pai 41 On irect writings (salvage eucte)............................... 41 42 On reinsurance assume (salvage eucte)......................... 42 43 Total (sum of lines 41 an 42)..................................... 43 44 Deuct: recoveries on reinsurance cee............................ 44 45 Net losses pai................................................ 45 c Ocean Marine Expenses Pai Incurre 1 Total 2 Foregin 3 Forei ocean marine ocean marine ocean ma Column (1) shoul aggree with corresponing lines in business business busines Insurance Expense Exhibit 46 Loss ajustment expenses....................................... 46 47 Commission an brokerage....................................... 47 48 Other acquisition, fiel supervision an collection expenses.............. 48 49 General expenses.............................................. 49 50 Taxes licenses an fees excluing feeral income an real estate taxes.... 50 51 Totals........................................................ 51 Deuct: total of co 52 Net Unite States ocean marine expenses incurre carry to line 7...........................................................................

Classification of business within Unite States within 7 Lines ates 4 Marine 5 Marine, other 6 All in column (4) es as per than as per other written in tal col. 2) Section 29A Section 29A classes Massachusetts 2001 63-29A Page 5 *a *b ** 8 Lines in Column (4) Applying to Losses Incurre Prior to January 1, 1945 or Date Applicable Incurre gn 4 Ocean marine 5 Lines in column (4) rine business within applying to business of s Unite States years prior to January 1, 1945 or ate applicable **Show separation into (a) authorize an (b) unauthorize reinsurance. **Reconciliation of line 40, column 7 with annual statement, page 14. Show **pools, exchange, treaties an the amounts assume an cee through each. lumn (5).... 50

2001 63-29A Page 6 Section 29A Unite States Marine Insurance Net Losses Incurre in Taxable Year Note that the stanar cut-off ate for lines 51 to 59 is December 31, 1944. 53 Payments uring the taxable year on marine losses (salvage eucte) incurre since December 31, 1944, less recoveries on reinsurance on losses incurre since December 31, 1944 (line 45, column 4 less column 8).......... 53 $ 54 A reinsurance recoverable December 31 of the previous year on pai marine losses incurre since December 31, 1944..................................................................... 54 55 Total............................................................................................. 55 56 Deuct reinsurance recoverable December 31 of the taxable year on pai marine losses incurre since December 31, 1944............................................................................ 56 57 Balance.......................................................................................... 57 58 A net amount unpai December 31 of the taxable year on marine losses incurre since December 31, 1944 (Net as to recoveries on reinsurance cee).............................................................. 58 Amount exclue on losses incurre prior to January 1, 1945........................... *$ 59 Total............................................................................................. 59 60 Deuct net amount unpai December 31 of the previous year on marine losses incurre since December 31, 1944 (Net as to recoveries on reinsurance cee).............................................................. 60 Amount exclue on losses incurre prior to January 1, 1945............................ $ 61 Net losses incurre uring the taxable year of 2001........................................................ 61 *Amount of actual Unite States unpai losses is require.

2001 63-29A Page 7 Ratios Note: In the following, Net Premiums mean Direct Premiums plus Reinsurance Assume, both net of Returne Premiums, an less Net Reinsurance Premiums Cee. 62 Net premiums on 29A Marine business written in Unite States in 2001 (line 40, column 4).......................... 62 $ 63 The same written in 2000............................................................................. 63 64 The same written in 1999............................................................................. 64 65 Total for 3-year perio............................................................................... 65 66 Average (¹ ₃ of line 65)............................................................................... 66 67 Net premiums on 29A Marine business written in Massachusetts in 2001 (line 40, column 7)........................ 67 68 The same written in 2000............................................................................. 68 69 The same written in 1999............................................................................. 69 70 Total for 3-year perio............................................................................... 70 71 Average (¹ ₃ of line 70)............................................................................... 71 72 Average Massachusetts Marine Premiums (line 71) $................................... 72 * % Average Unite States Marine Premiums (line 66) $ *Carry ecimal to six places