Rhode Island Surplus Line Broker Return of Gross Premiums

Surplus Line Broker Return of Gross Premiums
2023 T-71A
State of Rhode Island Division of Taxation

2023 Form T-71A

23111799990101

Surplus Line Broker Return of Gross Premiums
Name

Federal employer identification number

Address

State or country of incorporation or organization

Address 2

National producer number

City, town or post office

State

ZIP code

E-mail address

Computation of Tax

Tax and
Payments
Balance
Due
Refund

1 Gross premium charged.......................................................................... 1
2 Returned Premiums................................................................................. 2
3 Net Taxable Premium. Subtract line 2 from line 1.......................................................................................
4 SURPLUS LINE BROKER TAX. Rate: 4%. Multiply line 3 by the tax rate of 4% (0.04)............................
5 Payments made on 2023 declaration of estimated tax ........................... 5
6 Net Tax Due. Subtract line 5 from line 4.....................................................................................................
7
8
9
10
11

3
4

6
7
Interest Due: (a) Late payment _____________ (b) Underestimating __________ .................................
Total Due with Return. Add lines 6 and 7.................................................................................................... 8
Overpayment. Subtract lines 4 and 7 from line 5....................................................................................... 9
10
Amount of overpayment to be applied to 2024 estimated tax.....................................................................
Amount to be refunded. Subtract line 10 from line 9.................................................................................. 11

INSURANCE AGENCIES:
Enter the Federal Identification Number of the Agency ONLY in the space provided above. Do NOT enter a broker’s social security number. You
MUST complete page 2, LIST OF BROKERS, in order for the individual broker licenses to be renewed. If page 2 is not completed, license renewals
may be delayed. You may submit as many copies of page 2 as needed.
INDIVIDUALS:
Enter your National Producer Number in the space provided above. Do NOT enter the insurance agency’s federal identification number.
Skip page 2 and go directly to page 3.
Line 1:

Gross Premium Charged - From the Return Supplement on
page 3, add the Premium Column Total to the Additional
Premium Column Total.

Line 2:

Amount of Returned Premiums - From the Return Supplement
on page 3, enter the amount from Return Premium Column
Total.

Line 3:

Net Taxable Premium. Subtract line 2 from line 1.

Line 4:

Surplus Line Broker Tax. Multiply line 3 times rate of 4% (0.04).

Line 5:

Enter the amount of estimated tax paid for tax year 2023, plus
any amounts applied from tax year 2022.

Line 6:

Net Tax Due. Subtract line 5 from line 4.

Line 7:

Interest Due:
(a) Late payment interest: 12% per annum, 1.0% per month.
(b) Underestimating interest - see Regulation 280-RICR-20-25-5.
Enter the sum of lines (a) and (b) on line 7.

Line 8:

Total Due with Return. Add lines 6 and 7.

Line 9:

Overpayment. Subtract lines 4 and 7 from line 5.

Line 10:

Enter the amount from line 9 to be applied to 2024
Estimated Tax.

Line 11:

Subtract line 10 from line 9. This is the amount to be refunded.

Submit Form T-71A and remit any payment due by April 1, 2024.

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, it is true, accurate and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Authorized officer signature
Print name
Date
Telephone number

Paid preparer signature

Paid preparer address

Print name

City, town or post office

Date

State

ZIP code

Telephone number

PTIN

May the Division of Taxation contact your preparer? YES
Rhode Island has an Electonic Mandate for filing a return and remitting a payment.
See the Business Forms General Instructions for more information on the requirements and how to file and pay.

Revised
08/2023

State of Rhode Island Division of Taxation

2023 Form T-71A

23111799990102

Surplus Line Broker Return of Gross Premiums
Name

Federal employer identification number

Broker #1

First
name

National
producer
number

Address

Broker #2

SSN

First
name

National
producer
number

Address

Broker #3

SSN

First
name

National
producer
number

Address

Broker #4

SSN

First
name

National
producer
number

Address

SSN

First
name

National
producer
number

Address

SSN

First
name

National
producer
number

Address

SSN

First
name

National
producer
number

Address

SSN

First
name

National
producer
number

Address

SSN

First
name

National
producer
number

Address

SSN

First
name

National
producer
number

Address

Broker #10

Broker #9

Broker #8

Broker #7

Broker #6

SSN

Broker #5

This page must be completed by agencies/companies with individual licensees covered under this
return to prevent a delay in renewing the licenses of those individuals.

SSN/FEIN:
Signature of broker:
Licensee:

Page 2

MI

Last
name

MI

Last
name

MI

Last
name

MI

Last
name

MI

Last
name

MI

Last
name

MI

Last
name

MI

Last
name

MI

Last
name

MI

Last
name

State of Rhode Island Division of Taxation

2023 Form T-71A

IMAGEONLY

Surplus Line Broker Return of Gross Premiums
Name

Federal employer identification number/social security number

For policies invoiced from January 1, 2023 through December 31, 2023
NAIC#

Carrier
Name

Company carrying the risk,
not the Wholesale Broker

Name of
Insured

Risk
Location

Invoice
Date

Premium totals - - - >
SSN/FEIN:
Signature of broker:
Licensee:

Page 3

Premium

Return
Premium

Additional
Premium