Pennsylvania Gross Premiums Tax Report

Gross Premiums Tax Report
Gross Premiums Tax - Premiums Paid to Unauthorized Foreign Insurance Companies (RCT-122)
IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING
FILL IN FORM USING ALL CAPS. DO NOT USE DASHES (-) OR SLASHES (/) IN ANY FIELD. ENTER DATES AS MMDDYYYY. USE WHOLE DOLLARS ONLY.

1220022105

rct-122

OFFICIAL USE ONLY
Date Received (Official Use Only)

Page 1 of 3

08-22 (FI)

gross PreMIUMs taX - PreMIUMs PaID to
UNaUtHorIZeD foreIgN INsUraNce coMPaNIes
START

Revenue ID

Federal ID (FEIN)

c
Policies Purchased or
Renewed During ONE
Month and Year End:

Parent Corporation (FEIN)

➜

_ _ /_ _ _ _

rePort oNe MoNtH oNLY.
Due Date: (see Instructions)

Taxpayer Name

Please select correct letter in drop down
Check to Indicate a Change of Address
Amended Report (Include REV-1175.)
First Report

First Line of Address
Second Line of Address

Final Report (See Instructions.)
City

State

ZIP
Out of Existence Date:

Phone
Email

Use wHoLe DoLLars oNLY

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Gross Premiums Tax on Premiums Paid to Unauthorized Companies (Page 2, Line 9)
Total Estimated Payments
Total Payments Carried Forward From Prior Year Return
Total “Restricted” Tax Credits
Total Credit: (Line 2 plus Line 3 plus Line 4)
Tax Due: (If Line 1 is more than Line 5, enter the difference here.)
Remittance
Overpayment: (If Line 5 is more than Line 1, enter the difference here.)
Refund: (Amount of Line 8 to be refunded after offsetting all unpaid liabilities)
Transfer: (Amount of Line 8 to be credited to the next tax year after offsetting
all unpaid liabilities)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

1220022105

corporate officer Information:

Officer Last Name

Social Security
Number of Officer

Officer First Name
Title of Officer

Phone
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

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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.

1220022205

rct-122

08-22 (FI)

Revenue ID

Page 2 of 3

caLcULatIoN of taX

c

Use wHoLe DoLLars oNLY
Life Insurance and annuities
1.
2.
3.
4.

Total Gross Premiums on Life Insurance and Annuities (Schedule A)
Total of Premiums returned on cancelled policies of
Life Insurance and Annuities
Taxable Gross Premiums on Life Insurance and Annuities (Line 1 minus Line 2)
Tax on Taxable Gross Premiums on Life Insurance and Annuities
(Line 3 times tax rate – See Instructions.)

1.
2.
3.
4.

all other types of Insurance (other than Life Insurance and annuities)
5.
6.
7.
8.
9.

Total Gross Premiums on all other types of Insurance, (Schedule B)
Total of Premiums returned on cancelled policies of all other types
of insurance
Taxable Gross Premiums on all other types of insurance (Line 5 minus Line 6)
Tax on Taxable Gross Premiums on all other types of insurance
(Line 7 times tax rate – See Instructions.)
Total Tax (Line 4 plus Line 8)

Preparer’s Information:

5.
6.
7.
8.
9.

1220022205

Firm Name
Firm FEIN
Address
City
State
ZIP

Individual Preparer Name
Phone
Email
Social Security Number
or PTIN

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

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rct-122

08-22 (FI)

Page 3 of 3

Revenue ID

schedule a
Life Insurance and annuities

1220022305
Name of Insurance company

1220022305

Location of risk

Policy
Number

Beginning
Date of Policy
and term

type of
Insurance

amount of
Insurance

gross Premiums

Policies Purchased or Renewed

carry to Page 2, Line 1

total

carry to Page 2, Line 2

total

Policies Cancelled

schedule B
other than Life Insurance and annuities
Name of Insurance company

Location of risk

Policy
Number

Beginning
Date of Policy
and term

type of
Insurance

amount of
Insurance

gross Premiums

Policies Purchased or Renewed

carry to Page 2, Line 5

total

carry to Page 2, Line 6

total

Policies Cancelled

1220022305
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THIS PAGE DOES NOT PRINT

Instructions for RCT-122

Gross Premiums Tax - Premiums Paid to Unauthorized Foreign Insurance Companies

RCT-122 (SU) IN 10-23

GENERAL INFORMATION
● The RCT-122 can now be filed electronically at
mypath.pa.gov.
REMINDER
● THE RCT-122 REPORT CANNOT INCLUDE MORE
THAN ONE MONTH
● All payments of $1,000 or more must be made electronically or by certified or cashier’s check remitted in person or by express mail courier.
● Use only whole dollars when preparing tax reports.
● Taxpayers may request a 60 day extension to file this
report electronically via myPATH or by filing the
REV-426.
NOTE: The automatic PA extension provided
by Act 52 of 2013 to those with valid federal
extensions DOES NOT apply to this tax.
● The penalty imposed for failure to file timely reports is a
minimum of $500, regardless of the determined tax liability, plus an additional 1 percent of any determined tax
liability over $25,000.
● Use ONLY the most current, non-year-specific tax form
and instructions for filing ALL tax periods. If an
amended report must be filed, taxpayers must use
the most current, non-year-specific tax form, completing all sections of the form. REV-1175, Schedule
AR (explanation for amending), must be included
when filing an amended report.
● A signed copy of the RCT-122 tax report must be sent
to the Pennsylvania Surplus Lines Association on behalf
of the Pennsylvania Insurance Department, to 180
Sheree Blvd., Ste. 3100, Exton, PA 19341.
● The tax liability reported on RCT-122 cannot be less
than zero; instead the taxpayer must file a petition for
refund.
REPORT CHECKLIST
Make sure you include the following to file your report properly and completely:
● Negative amounts must be written using a minus sign
preceding the number. Do not use parentheses.
● Complete RCT-122, Gross Premiums Tax Report,
for premiums paid to unauthorized foreign insurance
companies, associations, exchanges, etc.

● Complete Schedule A and Schedule B (Include any cancelled policies)
● Corporate officer’s/insured’s signature on Page 1 and
preparer’s signature and PTIN on Page 2, if applicable
● A signed copy of the RCT-122 tax report must be sent
to the Pennsylvania Surplus Lines Association on behalf
of the Pennsylvania Insurance Department, to 180
Sheree Blvd., Ste. 3100, Exton, PA 19341
IMPOSITION, BASE, AND RATE
Gross premiums tax for premiums paid to unauthorized foreign or alien insurance companies is imposed on the insured
rather than on the insurance carrier. Anyone who enters into
a contract of insurance or reinsurance with a foreign or alien
insurer not licensed to do business in Pennsylvania is subject to the tax on insurance premiums. The tax is imposed
at 2 percent of life insurance and annuity gross premiums
and 3 percent on premiums for all other types of insurance.
The tax must be remitted to the Pennsylvania Department
of Revenue when the insured enters into the insurance contract and makes a periodic payment. Insurance companies
authorized to do business in Pennsylvania are subject to a
tax on gross premiums of reinsurance when the reinsurance
is with companies not authorized to do business in Pennsylvania. For more information, see Act of July 6, 1917, P.L.
723, as amended by the Act of Jan. 24, 1966.
LOCATION OF RISK
If the policy involves risk located in multiple states including
Pennsylvania, the taxable premium shall be levied as follows:
If Pennsylvania is the home state of the insured, the gross
premium shall be taxable to Pennsylvania. For more information see 40 P.S. § 991.1602, 40 P.S. § 991.1621 and 40
P.S. § 991.1622.
REVENUE ID, FEDERAL EMPLOYER IDENTIFICATION
NUMBER (FEIN), PARENT CORPORATION FEIN, NAME,
AND ADDRESS
The Revenue ID number, FEIN, name, and complete mailing
address must be provided. If the taxpayer is a subsidiary of
a corporation, the parent corporation’s FEIN must be provided. Also provide the telephone number and email of the
taxpayer.
TAX PERIOD
Enter month and year (MMYYYY) for tax period end.

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REPORT DUE DATE
The report is due within 30 days after the last day of the
month in which the insurance was procured. If multiple purchases of such insurance are expected to occur more than
once during a particular month, only one tax report should
be prepared summarizing each day’s transaction and submitted upon closing of the month. The beginning date of all
policies must be the same as the file month indicated. The
penalty imposed for failure to file timely reports is now a minimum of $500, regardless of the determined tax liability, plus
an additional 1 percent of any determined tax liability over
$25,000.
ADDRESS CHANGE
Enter “Y” in the block on Page 1 if the address of the corporation has changed from prior tax periods. The current
mailing address should be reflected on the report.
AMENDED REPORT
Enter “Y” in the block on Page 1 if you are filing an amended
report to add, delete, or adjust information. Provide documentation to support all changes being made. An amended
report should only be filed if an original report was filed
previously for the same period.
The taxpayer has three (3) years after the due date of the
original report to file an amended report. If the original report
was properly extended, then the taxpayer has three (3)
years after the extended due date to file an amended report.
The department may adjust the tax originally reported based
on information from the amended report. The taxpayer must
consent to extend the assessment period. If the amended
report is timely filed and the taxpayer consented to extend
the assessment period, the time period in which to assess
tax will be the greater of three years from the filed date of
the original report or one year from the filed date of the
amended report.
Regardless of the tax year being amended, taxpayers must
use the most current non-year-specific tax form, completing
all sections of the report. This includes those sections
originally filed and those sections being amended. All tax
liabilities should be recorded on Page 1. Taxpayers must
check the Amended Report check box on Page 1 and
include Schedule AR, REV-1175, with the report.
FIRST REPORT
Enter “Y” in the block on Page 1 if this is the taxpayer’s first
PA gross premiums tax filing.
FINAL REPORT
NOTE: If you wish to remain active, do not mark the
report as final.
● If this report will be the final report filed with the department, enter Y in the block on Page 1 and indicate the
effective date of the event as MMDDYYYY.
● Include a letter with the tax report verifying no policy or
policies were placed or renewed and no other insurance
policy was obtained from a company not authorized or
admitted by the Pennsylvania Insurance Department.
● Include a copy of the regulatory authority’s approval of
the merger, dissolution, plan of reorganization, and/or
articles of merger, if applicable.
2

RCT-122

● Provide the Revenue ID and FEIN of the surviving entity,
if applicable.
CORPORATE OFFICER INFORMATION
A corporate officer/insured must sign and date the tax report.
The signature must be original; photocopies or faxes will not
be accepted. Print the first and last name, title, Social Security number, telephone number, and email of the corporate
officer/insured.
PREPARER’S INFORMATION
Paid preparers must sign and date the tax report. If the preparer works for a firm, provide the name, FEIN, and address
of the firm along with the name, telephone number, email,
and PTIN/SSN of the individual preparing the report. If
the preparer is an individual without any association to a
firm, provide the name, address, telephone number, email,
and PTIN/SSN of the individual preparing the report.
EXTENSION REQUEST DUE DATE
To request a due date extension of up to 60 days to file the
report, you must file an extension request by the original report due date. You can request an extension on
mypath.pa.gov or by sending the REV-426. However, an
extension of time to file does not extend the deadline for payment of tax, and an extension request must be accompanied
by payment of taxes owed for the taxable year for which the
extension is requested.
Mail the extension coupon separately from all other forms.
A taxpayer using an electronic method to make a payment
with an extension request should not submit the extension
coupon. Do not use the extension coupon to remit other
unpaid liabilities within the account.
PAYMENT AND MAILING INFORMATION
All payments of $1,000 or more must be made electronically
or by certified or cashier’s check mailed to:
PA DEPARTMENT OF REVENUE
PO BOX 280404
HARRISBURG PA 17128-0404
Tax returns and certified or cashier’s check may be remitted
in person or by express mail courier. Mail payments and
returns to the following address:
PA DEPARTMENT OF REVENUE
1854 BROOKWOOD ST
HARRISBURG PA 17104
Payments under $1,000 may be remitted by mail, made
payable to the PA Department of Revenue. Mail payments,
extension requests and returns to the following address:
PA DEPARTMENT OF REVENUE
PO BOX 280427
HARRISBURG PA 17128-0427
Failure to make a payment by an approved method will
result in the imposition of a 3 percent penalty of the tax due,
up to $500. For more information on electronic filing options,
visit mypath.pa.gov.
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CURRENT PERIOD OVERPAYMENT
If an overpayment exists on Page 1 of the RCT-122, the taxpayer must instruct the department to refund or transfer
overpayment as indicated below.
REFUND
Identify the amount to refund from the current tax period
overpayment. Prior to any refund, the department will offset
current period liabilities and other unpaid liabilities within the
account.
TRANSFER
Identify the amount to transfer from the current tax period
overpayment to the next tax period. Prior to any transfer, the
department will offset current period liabilities and other
unpaid liabilities within the account.
NOTE: If no option is selected, the department will
automatically transfer any overpayment to the next tax
period after offsetting current period liabilities and other unpaid liabilities within the account.
REQUESTS FOR REFUND OR TRANSFER
OF AVAILABLE CREDIT
Requests for refund or transfer of available credit from prior
periods can be requested on company letterhead, signed
by an authorized representative, and emailed to
[email protected].
Please do not duplicate requests for refund and/or transfer
by submitting both RCT-122 and written correspondence.

CONTACT INFORMATION
● For additional information regarding electronic payments
visit the departments Online Customer Service Center
at revenue.pa.gov.
● Questions regarding payments or refunds, email
[email protected].
● General business tax questions, visit the department's
Online Customer Service Center at revenue.pa.gov.
● Business taxpayers and tax practitioners have the ability
to receive and view department issued electronic
statement of accounts and correspondence
electronically by visiting mypath.pa.gov.
● If you have questions regarding filing a copy of this
report to the Pennsylvania Surplus Lines Association,
call the Pennsylvania Surplus Lines Association at
610-594-1340 or visit their website at www.pasla.org.

LINE INSTRUCTIONS
RCT-122 should be completed in the following order:
(Page instructions start with Page 3 below.)
STEP 1
Complete the taxpayer information section and any applicable
questions at the top of Page 1.
STEP 2
Enter the Revenue ID and other taxpayer information in the
designated fields at the top of each page.
STEP 3
Complete Page 3, Schedule A and/or Schedule B.

STEP 4
Complete Page 2, Calculation of Tax.
STEP 5
Complete Page 1, Lines 1 through 10.
STEP 6
Complete the corporate officer information section, sign, and
date at the bottom of Page 1.
STEP 7
Complete the preparer information section, sign, and date
at the bottom of Page 2, if applicable.
STEP 8
Mail the completed report and any supporting schedules to
the PA Department of Revenue.
STEP 9
Send a signed copy of the RCT-122 to the Pennsylvania
Surplus Lines Association on behalf of the Pennsylvania
Insurance Department, to 180 Sheree Blvd., Ste. 3100,
Exton, PA 19341.

PAGE 3
SCHEDULE A AND/OR SCHEDULE B
Complete Schedule A for life insurance and annuities and
Schedule B for all other types of insurance.
NAME OF INSURANCE COMPANY
Enter the name of the unauthorized foreign or alien insurance company used to procure the policy.
LOCATION OF RISK
Enter the location(s) the risk will cover.
NOTE: If the policy involves risk located in multiple
states including Pennsylvania, the taxable premium
shall be levied as follows:
If Pennsylvania is the home state of the insured, the gross
premium shall be taxable to Pennsylvania. For more information see 40 P.S. § 991.1602, 40 P.S. § 991.1621 and 40
P.S. § 991.1622.
POLICY NUMBER
Enter the policy number.
BEGINNING DATE OF POLICY AND TERM
Enter the beginning date and term of the policy. The beginning date of all policies must be the same as the file month
indicated on Page 1 of RCT-122.
TYPE OF INSURANCE
Enter the type of insurance being procured, life or annuity,
in Schedule A only, and all others in Schedule B.
AMOUNT OF INSURANCE
Enter the amount of the insurance policy.
GROSS PREMIUMS
Enter the amount of gross premiums on the policy.

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3

TOTAL
Enter the total amount of insurance and gross premiums for
each schedule.
Include cancelled policies in the Policies Cancelled section
of Schedule A and/or Schedule B.

PAGE 2
CALCULATION OF TAX
LIFE INSURANCE AND ANNUITIES

LINE 1
TOTAL GROSS PREMIUMS ON LIFE INSURANCE AND
ANNUITIES (SCHEDULE A)
Enter the total gross premiums on life insurance and annuities reported on Page 3, Schedule A.

LINE 2
TOTAL OF PREMIUMS RETURNED ON CANCELLED
POLICIES OF LIFE INSURANCE AND ANNUITIES
Enter the total premiums returned on cancelled policies of
life insurance and annuities. A schedule identifying the name
of the insurance company, location of risk, policy number,
beginning date of policy, date of cancellation, type of insurance, and amount of cancellation for each cancelled policy
of life insurance and annuities must be provided. Adjustment
for cancelled policies cannot reduce taxable gross premiums
to less than zero.

LINE 3
TAXABLE GROSS PREMIUMS ON LIFE INSURANCE
AND ANNUITIES
Subtract Line 2 from Line 1.

LINE 4
TAX ON TAXABLE GROSS PREMIUMS ON LIFE
INSURANCE AND ANNUITIES
Multiply Line 3 by 0.02.

4

RCT-122

ALL OTHER TYPES OF INSURANCE (OTHER THAN LIFE
INSURANCE AND ANNUITIES)

LINE 5
TOTAL GROSS PREMIUMS ON ALL OTHER TYPES OF
INSURANCE (SCHEDULE B)
Enter the total gross premiums on all other types of insurance reported on Page 3, Schedule B.

LINE 6
TOTAL OF PREMIUMS RETURNED ON CANCELLED
POLICIES OF ALL OTHER TYPES OF INSURANCE
Enter the total premiums returned on cancelled policies of
all other types of insurance. A schedule identifying the name
of the insurance company, location of risk, policy number,
beginning date of policy, date of cancellation, type of insurance, and amount of cancellation for each cancelled policy
of all other types of insurance must be provided. Adjustment
for cancelled policies cannot reduce taxable gross premiums
to less than zero.

LINE 7
TAXABLE GROSS PREMIUMS ON ALL OTHER TYPES
OF INSURANCE
Subtract Line 6 from Line 5.

LINE 8
TAX ON TAXABLE GROSS PREMIUMS ON ALL OTHER
TYPES OF INSURANCE
Multiply Line 7 by 0.03.

LINE 9
TOTAL TAX
Enter the sum of Lines 4 and 8. Carry to RCT-122, Page 1,
Line 1.
Tax liability cannot be less than zero.

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