- 3 -
|
Michigan Department of Treasury
MBT Insurance Worksheet A (Rev. 12-21)
2021 Michigan Business Tax Insurance Worksheet A
Include a copy of Worksheet A with your MBT return.
Taxpayer Name )HGHUDO (PSOR\HU ,GHQWL¿FDWLRQ 1XPEHU )(,1
DIRECT PREMIUMS WRITTEN IN MICHIGAN AB
4XDOL¿HG +HDOWK ,QV 3ROLFLHV All Other Policies
1. Gross direct premiums written in Michigan................................................................ 1. 00 00
2. Premiums on policies not taken................................................................................. 2. 00 00
3. Returned premiums on canceled policies.................................................................. 3. 00 00
4. Receipts on sales of annuities ................................................................................... 4. 00 00
5. Receipts on reinsurance assumed (see instructions) ................................................ 5. 00 00
6. Add lines 2 through 5................................................................................................. 6. 00 00
7. Direct Premiums Written in Michigan. Subtract line 6 from line 1.
If less than zero, enter zero ....................................................................................... 7. 00 00
DISABILITY INSURANCE EXEMPTION
8. Disability insurance premiums written in Michigan, not including credit or disability
income insurance premiums (see instructions) ........................................................... 8. 00 00
9. Proportional share of limit and phase-out.
Column A: Divide line 8, column A, by the sum of line 8, columns A and B.
Column B: Divide line 8, column B, by the sum of line 8, columns A and B ............. 9. %%
10. Enter the sum of all disability insurance premiums from both columns of line 8
OR $190,000,000, whichever is less ............................................................................................... 10. 00
11. Gross direct premiums from insurance carrier services everywhere............................................... 11. 00
12. Phase out ........................................................................................................................................ 12. 280,000,000 00
13. Subtract line 12 from line 11. If less than zero, enter zero .............................................................. 13. 00
14. Exemption reduction. Multiply line 13 by 2 ...................................................................................... 14. 00
15. Subtract line 14 from line 10. If less than zero, enter zero .............................................................. 15. 00
16. Allocated reduced exemption.
Column A: Multiply line 15 by the percentage on line 9, column A.
Column B: Multiply line 15 by the percentage on line 9, column B ......................... 16. 00 00
17. Adjusted tax base.
Column A: Subtract line 16, column A, from line 7, column A.
Column B: Subtract line 16, column B, from line 7, column B................................. 17. 00 00
18. Multiply line 17, column A, by 0.4835% (0.004835) and column B by 1.25% (0.0125) . 18. 00 00
19. Tax before credits. Add line 18, columns A and B............................................................................ 19. 00
CREDITS
20. Enter amounts paid from 1/1/2020 to 12/31/2020 to each of the following:
a. Michigan Workers’ Compensation Placement Facility ..................................................................................... 20a. 00
b. Michigan Basic Property Insurance Association .............................................................................................. 20b. 00
c. Michigan Automobile Insurance Placement Facility ........................................................................................ 20c. 00
d. Property and Casualty Guaranty Association .................................................................................................. 20d. 00
e. Michigan Life and Health Insurance Guaranty Association ............................................................................. 20e. 00
21. Add lines 20a through 20e...................................................................................................................................... 21. 00
22. Michigan Examination Fees or Regulatory Fee...................................................................................................... 22. 00
23. Credit. Multiply line 22 by 50% (0.50) ..................................................................................................................... 23. 00
24. Tax liability before recapture. Subtract line 21 and line 23 from line 19. If less than or equal to $100, enter zero.
Carry amount to Form 4974, line 15 ....................................................................................................................... 24. 00
|