Fillable Form 1120-PC 2019 Insurance Company Income Tax Return

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Form 1120-PC 2019 Insurance Company Income Tax Return

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Version A, Cycle 13
INTERNAL USE ONLY
DRAFT AS OF
February 28, 2020
Form 1120-PC
2019
U.S. Property and Casualty Insurance Company
Income Tax Return
Department of the Treasury
Internal Revenue Service
For calendar year 2019, or tax year beginning , 2019, ending , 20
▶
Go to www.irs.gov/Form1120PC for instructions and the latest information.
OMB No. 1545-0123
Please
print
or
type
Name
Number, street, and room or suite no. If a P.O. box, see instructions.
City or town, state or province, country, and ZIP or foreign postal code
A Check if:
1 Consolidated return
(attach Form 851) .
2 Life-nonlife consoli-
dated return . .
3
Schedule M-3
(Form 1120-PC)
attached . . .
B Employer identification number
C Date incorporated
D
Check applicable box if an election
has been made under section(s):
831(b) 953(c)(3)(C) 953(d)
E Check if:
(1)
Final return
(2)
Name change
(3)
Address change
(4)
Amended return
Tax Computation and Payments
1 Taxable income (Schedule A, line 37) . . . . . . . . . . . . . . . . . . . . . 1
2 Taxable investment income for electing small companies (Schedule B, line 21) . . . . . . . . . 2
3 Check if a member of a controlled group (attach Schedule O (Form 1120)) . . . . . . . .
▶
4 Income tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Enter amount of tax that a reciprocal must include . . . . . . . . . . . . . . . . . 5
6 Base erosion minimum tax amount (attach Form 8991) . . . . . . . . . . . . . . . . 6
7 Add lines 4 through 6 . . . . . . . . . . . . . . . . . . . . . . . . . 7
8a Foreign tax credit (attach Form 1118) . . . . . . . . . . . . 8a
b Credit from Form 8834 (attach Form 8834) . . . . . . . . . . 8b
c General business credit (attach Form 3800) . . . . . . . . . . 8c
d Credit for prior year minimum tax (attach Form 8827) . . . . . . . 8d
e Bond credits from Form 8912 . . . . . . . . . . . . . . 8e
f Total credits. Add lines 8a through 8e . . . . . . . . . . . . . . . . . . . . 8f
9 Subtract line 8f from line 7 . . . . . . . . . . . . . . . . . . . . . . . . 9
10 Foreign corporations—Tax on income not connected with U.S. business . . . . . . . . . . 10
11 Personal holding company tax (attach Schedule PH (Form 1120)) . . . . . . . . . . . . 11
12 Other taxes. Check if from: Form 4255 Form 8611 Other (attach statement) . . 12
13 Total tax. Add lines 9 through 12 . . . . . . . . . . . . . . . . . . . . . . 13
14 2019 Net 965 tax liability paid from Form 965-B, Part II, column (k), line 3 . . . . . . . . . . 14
15a 2018 overpayment credited to 2019 . . .
15a
b Reserved for future use . . . . . . . 15b
c
2019 estimated tax payments (see instructions)
15c
d 2019 Net 965 tax liability from Form 965-B,
Part I, column (d), line 3 . . . . . . .
15d
e Less 2019 refund applied for on Form 4466 . 15e ( )
f Enter the total of lines 15a through 15d less line 15e . . . . . . . 15f
g Tax deposited with Form 7004 . . . . . . . . . . . . . .
15g
h Credit by reciprocal for tax paid by attorney-in-fact under section 835(d) . 15h
i Other credits and payments . . . . . . . . . . . . . . 15i
j Refundable credit from Form 8827, line 5c . . . . . . . . . .
15j
15k
16 Estimated tax penalty (see instructions). Check if Form 2220 is attached . . . . . . . .
▶
16
17 Amount owed. If line 15k is smaller than the total of lines 13, 14, and 16, enter amount owed . . . . 17
18 Overpayment. If line 15k is larger than the total of lines 13, 14, and 16, enter amount overpaid . . . . 18
19
Enter amount from line 18: Credited to 2020 estimated tax
▶
Refunded
▶
19
Sign
Here
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true,
correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
▲
Signature of officer
Date
▲
Title
May the IRS discuss this return
with the preparer shown below?
See instructions
Yes No
Paid
Preparer
Use Only
Print/Type preparer’s name Preparer’s signature Date
Check if
self-employed
PTIN
Firm’s name
▶
Firm’s address
▶
Firm’s EIN
▶
Phone no.
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 64270Q
Form 1120-PC (2019)
Version A, Cycle 13
INTERNAL USE ONLY
DRAFT AS OF
February 28, 2020
Form 1120-PC (2019)
Page 2
Schedule A Taxable Income—Section 832 (see instructions)
Income
1 Premiums earned (Schedule E, line 7) . . . . . . . . . . . . . . . . . . . . . 1
2 Dividends and inclusions (Schedule C, line 17) . . . . . . . . . . . . . . . . . . 2
(a) Interest received
(b) Amortization of
premium
3a Interest (including tax-exempt interest) . . . . .
b Interest exempt under section 103 . . . . . . .
c Subtract line 3b from line 3a . . . . . . . .
d Taxable interest. Subtract line 3c, column (b) from line 3c, column (a) . . . . . . . . . . . 3d
4 Rents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Royalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Capital gain net income (attach Schedule D (Form 1120)) . . . . . . . . . . . . . . . 6
7 Net gain or (loss) from Form 4797, Part II, line 17 (attach Form 4797) . . . . . . . . . . . 7
8 Certain mutual fire or flood insurance company premiums (section 832(b)(1)(D)) . . . . . . . . 8
9 Income on account of special income and deduction accounts . . . . . . . . . . . . . 9
10 Income from protection against loss account (see instructions) . . . . . . . . . . . . . 10
11 Mutual interinsurers or reciprocal underwriters—decrease in subscriber accounts . . . . . . . . 11
12 Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Other income (attach statement) . . . . . . . . . . . . . . . . . . . . . . 13
14 Gross income. Add lines 1 through 13 . . . . . . . . . . . . . . . . . . . .
14
Deductions (See instructions for limitations on deductions.)
15 Compensation of officers (attach statement) (see instructions) . . . . . . . . . . . . . 15
16 Salaries and wages (less employment credits) . . . . . . . . . . . . . . . . . . 16
17 Agency balances and bills receivable that became worthless during the tax year . . . . . . . . 17
18 Rents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
19 Taxes and licenses . . . . . . . . . . . . . . . . . . . . . . . . . . 19
20a
Interest
▶
b
Less tax-exempt interest exp.
▶
c Bal.
▶
20c
21 Charitable contributions . . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Depreciation (attach Form 4562) . . . . . . . . . . . . . . . . . . . . . . 22
23 Depletion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
24 Pension, profit-sharing, etc., plans . . . . . . . . . . . . . . . . . . . . . 24
25 Employee benefit programs . . . . . . . . . . . . . . . . . . . . . . . 25
26 Losses incurred (Schedule F, line 14) . . . . . . . . . . . . . . . . . . . . . 26
27 Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . 27
28 Other capital losses (Schedule G, line 12, column (g)) . . . . . . . . . . . . . . . . 28
29 Dividends to policyholders . . . . . . . . . . . . . . . . . . . . . . . . 29
30 Mutual interinsurers or reciprocal underwriters—increase in subscriber accounts . . . . . . . . 30
31 Other deductions (see instructions) (attach statement) . . . . . . . . . . . . . . . . 31
32 Total deductions. Add lines 15 through 31 . . . . . . . . . . . . . . . . . . . 32
33 Subtotal. Subtract line 32 from line 14 . . . . . . . . . . . . . . . . . . . . 33
34a Special deduction for section 833 organizations (Schedule H, line 6) . . . 34a
b Deduction on account of special income and deduction accounts . . . 34b
c Total. Add lines 34a and 34b . . . . . . . . . . . . . . . . . . . . . . . 34c
35 Subtotal. Subtract line 34c from line 33 . . . . . . . . . . . . . . . . . . . . 35
36a Dividends received and other special deductions (Schedule C, line 30) . . 36a
b Net operating loss deduction . . . . . . . . . . . . . . 36b
c Total. Add lines 36a and 36b . . . . . . . . . . . . . . . . . . . . . . . 36c
37 Taxable income. Subtract line 36c from line 35. Enter here and on page 1, line 1 . . . . . . . .
37
Form 1120-PC (2019)
Version A, Cycle 13
INTERNAL USE ONLY
DRAFT AS OF
February 28, 2020
Form 1120-PC (2019)
Page 3
Schedule B Part I—Taxable Investment Income of Electing Small Companies (section 834) (see instructions)
Income
(a) Interest received
(b) Amortization of
premium
1a Interest (including tax-exempt interest) . . . . .
b Interest exempt under section 103 . . . . . . .
c Subtract line 1b from line 1a . . . . . . . .
d Taxable interest. Subtract line 1c, column (b), from line 1c, column (a) . . . . . . . . . . . 1d
2 Dividends and inclusions (Schedule C, line 17) . . . . . . . . . . . . . . . . . . 2
3 Rents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Royalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Gross income from a trade or business, other than an insurance business, and from Form 4797 . . . 5
6 Income from leases described in sections 834(b)(1)(B) and 834(b)(1)(C) . . . . . . . . . . . 6
7 Capital gain net income from Schedule D (Form 1120), line 18 . . . . . . . . . . . . . 7
8 Gross investment income. Add lines 1d through 7 . . . . . . . . . . . . . . . . .
8
Deductions
9 Real estate taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
10 Other real estate expenses . . . . . . . . . . . . . . . . . . . . . . . . 10
11 Depreciation (attach Form 4562) . . . . . . . . . . . . . . . . . . . . . . 11
12 Depletion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Trade or business deductions as provided in section 834(c)(8) (attach statement) . . . . . . . . 13
14 Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
15 Other capital losses (Schedule G, line 12, column (g)) . . . . . . . . . . . . . . . . 15
16 Total. Add lines 9 through 15 . . . . . . . . . . . . . . . . . . . . . . . 16
17 Investment expenses (attach statement) . . . . . . . . . . . . . . . . . . . . 17
18 Total deductions. Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . 18
19 Subtract line 18 from line 8 . . . . . . . . . . . . . . . . . . . . . . . . 19
20 Dividends received and other special deductions (Schedule C, line 30) . . . . . . . . . . . 20
21 Taxable investment income. Subtract line 20 from line 19. Enter here and on page 1, line 2 . . . .
21
Part II—Invested Assets Book Values
Note: Complete only if claiming a deduction for general expenses allocated to investment income.
(a) Beginning of tax year (b) End of tax year
22 Real estate . . . . . . . . . . . . . . . . . . . . . . .
22
23 Mortgage loans . . . . . . . . . . . . . . . . . . . . . 23
24 Collateral loans . . . . . . . . . . . . . . . . . . . . . 24
25 Policy loans, including premium notes . . . . . . . . . . . . . . . 25
26 Bonds of domestic corporations . . . . . . . . . . . . . . . . 26
27 Stock of domestic corporations . . . . . . . . . . . . . . . . . 27
28 Government obligations, etc. . . . . . . . . . . . . . . . . . 28
29 Bank deposits bearing interest . . . . . . . . . . . . . . . . . 29
30 Other interest-bearing assets (attach statement) . . . . . . . . . . . . 30
31 Total. Add lines 22 through 30 . . . . . . . . . . . . . . . . . 31
32 Add columns (a) and (b), line 31 . . . . . . . . . . . . . . . . . . . . . . . . 32
33 Mean of invested assets for the tax year. Enter one-half of line 32 . . . . . . . . . . . . . . 33
34 Multiply line 33 by 0.0025 . . . . . . . . . . . . . . . . . . . . . . . . . 34
35 Income base. Line 1b, column (a), plus line 8 less the sum of line 1b, column (b),
and line 16 . . . . . . . . . . . . . . . . . . . . .
35
36 Multiply line 33 by 0.0375 . . . . . . . . . . . . . . . . 36
37 Subtract line 36 from line 35. Don’t enter less than zero . . . . . . . . 37
38 Multiply line 37 by 0.25 . . . . . . . . . . . . . . . . . . . . . . . . . . 38
39 Limitation on deduction for investment expenses. Add lines 34 and 38 . . . . . . . . . . . .
39
Form 1120-PC (2019)
Version A, Cycle 13
INTERNAL USE ONLY
DRAFT AS OF
February 28, 2020
Form 1120-PC (2019)
Page 4
Schedule C
Dividends, Inclusions, Dividends-Received Deduction, and Other Special Deductions
(see instructions)
Dividends and Inclusions
(a) Subject to section
832(b)(5)(B)
(b) Dividends and
inclusions
Income
1 Dividends from less-than-20%-owned domestic corporations (other than debt-
financed stock) . . . . . . . . . . . . . . . . . . . . .
1
2 Dividends from 20%-or-more-owned domestic corporations (other than debt-financed
stock) . . . . . . . . . . . . . . . . . . . . . . . .
2
3 Dividends on certain debt-financed stock of domestic and foreign corporations . . 3
4 Dividends on certain preferred stock of less-than-20%-owned public utilities . . . 4
5 Dividends on certain preferred stock of 20%-or-more-owned public utilities . . . . 5
6 Dividends from less-than-20%-owned foreign corporations and certain foreign sales
corporations (FSCs) . . . . . . . . . . . . . . . . . . . .
6
7 Dividends from 20%-or-more-owned foreign corporations and certain FSCs . . . 7
8 Dividends from wholly owned foreign subsidiaries and certain FSCs . . . . . . 8
9 Dividends from certain affiliated companies . . . . . . . . . . . . . 9
10 Foreign-source portion of dividends received from a specified 10%-owned foreign
corporation (excluding hybrid dividends) (see instructions) . . . . . . . . .
10
11 Dividends from foreign corporations not included on line 3, 6, 7, 8, or 10 (including any
hybrid dividend) . . . . . . . . . . . . . . . . . . . . .
11
12a
Subpart F inclusions derived from the sale by a controlled foreign corporation (CFC) of
the stock of a lower-tier foreign corporation treated as a dividend (attach Form(s)
5471) (see instructions) . . . . . . . . . . . . . . . . . . .
12a
b Subpart F inclusions derived from hybrid dividends of tiered corporations (attach
Form(s) 5471) (see instructions) . . . . . . . . . . . . . . . . .
12b
c Other inclusions from CFCs under subpart F not included on line 12a, 12b, 13, or 15
(attach Form(s) 5471) . . . . . . . . . . . . . . . . . . . .
12c
13 Global intangible low-taxed income (GILTI) (attach Forms 5471 and 8992) . . . . 13
14 Gross-up for foreign taxes deemed paid . . . . . . . . . . . . . . 14
15 Section 965(a) inclusion . . . . . . . . . . . . . . . . . . . 15
16 Other dividends (attach statement) . . . . . . . . . . . . . . . . 16
17 Total dividends and inclusions. Add lines 1 through 16. Enter here and on Schedule
A, line 2, or Schedule B, line 2, whichever applies . . . . . . . . . . .
17
Deductions
Dividends Received and
Other Special Deductions
(a) Subject to section
832(b)(5)(B)
(b)
Total dividends received
and special deductions
18 Multiply line 1 by 50% (0.50) . . . . . . . . . . . . . . . . . 18
19 Multiply line 2 by 65% (0.65) . . . . . . . . . . . . . . . . . 19
20 Deduction for line 3 (see instructions) . . . . . . . . . . . . . . . 20
21 Multiply line 4 by 23.3% (0.233) . . . . . . . . . . . . . . . . . 21
22 Multiply line 5 by 26.7% (0.267) . . . . . . . . . . . . . . . . . 22
23 Multiply line 6 by 50% (0.50) . . . . . . . . . . . . . . . . . 23
24 Multiply line 7 by 65% (0.65) . . . . . . . . . . . . . . . . . 24
25 Enter the amount from line 8 . . . . . . . . . . . . . . . . . 25
26 Total. Add lines 18 through 25. (See instructions for limitation.) . . . . . . . 26
27 Total. Add line 26, column (a), and line 9, column (a). Enter here and on Schedule F,
line 10 . . . . . . . . . . . . . . . . . . . . . . . .
27
28 Section 250 deduction (attach Form 8993) . . . . . . . . . . . . . . . . . . . .
28
29 Section 965(c) participation exemption (see instructions) . . . . . . . . . . . . . . . .
29
30 Total deductions. Add line 26, column (b), and lines 9, 10, 12a, 28, and 29, column (b). Enter here and on
Schedule A, line 36a, or Schedule B, line 20, whichever applies . . . . . . . . . . . . . .
30
Form 1120-PC (2019)
Version A, Cycle 13
INTERNAL USE ONLY
DRAFT AS OF
February 28, 2020
Form 1120-PC (2019)
Page 5
Schedule E Premiums Earned—Section 832 (see instructions)
1 Net premiums written . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Unearned premiums on outstanding business at the end of the preceding tax year:
a
Enter 100% of life insurance reserves included in unearned premiums
(section 832(b)(7)(A)) and unearned premiums of section 833 organizations. See
instructions . . . . . . . . . . . . . . . . . . . . .
2a
b Enter 90% of unearned premiums attributable to insuring certain securities . . 2b
c Discounted unearned premiums attributable to title insurance . . . . . . 2c
d Enter 80% of all other unearned premiums. See instructions . . . . . . 2d
e Total. Add lines 2a through 2d . . . . . . . . . . . . . . . . . . . . . . . . 2e
3 Total. Add lines 1 and 2e . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Unearned premiums on outstanding business at the end of the current tax year:
a
Enter 100% of life insurance reserves included in unearned premiums
(section 832(b)(7)(A)) and unearned premiums of section 833 organizations. See
instructions . . . . . . . . . . . . . . . . . . . . .
4a
b Enter 90% of unearned premiums attributable to insuring certain securities . . 4b
c Discounted unearned premiums attributable to title insurance . . . . . . 4c
d Enter 80% of all other unearned premiums. See instructions . . . . . . 4d
e Total. Add lines 4a through 4d . . . . . . . . . . . . . . . . . . . . . . . . 4e
5 Subtract line 4e from line 3 . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Transitional adjustments under section 832(b)(7)(D) (see instructions) . . . . . . . . . . . . . 6
7 Premiums earned. Add lines 5 and 6. Enter here and on Schedule A, line 1 . . . . . . . . . . .
7
Schedule F Losses Incurred (section 832) (see instructions)
1 Losses paid during the tax year (attach reconciliation to annual statement) . . . . . . . . . . . 1
2 Balance outstanding at the end of the current tax year for:
a Unpaid losses on life insurance contracts . . . . . . . . . . . . 2a
b Discounted unpaid losses . . . . . . . . . . . . . . . . 2b
c Total. Add lines 2a and 2b . . . . . . . . . . . . . . . . . . . . . . . . . 2c
3 Add lines 1 and 2c . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Balance outstanding at the end of the preceding tax year for:
a Unpaid losses on life insurance contracts . . . . . . . . . . . . 4a
b Discounted unpaid losses . . . . . . . . . . . . . . . . 4b
c Total. Add lines 4a and 4b . . . . . . . . . . . . . . . . . . . . . . . . . 4c
5 Subtract line 4c from line 3 . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Estimated salvage and reinsurance recoverable at the end of the preceding tax year . . . . . . . . 6
7 Estimated salvage and reinsurance recoverable at the end of the current tax year . . . . . . . . . 7
8 Losses incurred (line 5 plus line 6 less line 7) . . . . . . . . . . . . . . . . . . . . 8
9 Tax-exempt interest subject to section 832(b)(5)(B) . . . . . . . . . 9
10 Dividends-received deduction subject to section 832(b)(5)(B) (Schedule C, line
27) . . . . . . . . . . . . . . . . . . . . . . .
10
11 The increase in policy cash value of section 264(f) policies, as defined in section
805(a)(4)(F) . . . . . . . . . . . . . . . . . . . . .
11
12 Total. Add lines 9, 10, and 11 . . . . . . . . . . . . . . . . . . . . . . . . 12
13
Reduction of deduction under section 832(b)(5)(B). Multiply line 12 by applicable percentage. See instructions
. . 13
14 Losses incurred deductible under section 832(c)(4). Subtract line 13 from line 8. Enter here and on
Schedule A, line 26 . . . . . . . . . . . . . . . . . . . . . . . . . . .
14
Form 1120-PC (2019)
Version A, Cycle 13
INTERNAL USE ONLY
DRAFT AS OF
February 28, 2020
Form 1120-PC (2019)
Page 6
Schedule G
Other Capital Losses (see instructions)
Note: Capital assets sold or exchanged to meet abnormal insurance losses and to pay dividends and similar distributions to
policyholders
1 Dividends and similar distributions paid to policyholders . . . . . . . . . . . . . . . .
1
2 Losses paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Expenses paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Total. Add lines 1, 2, and 3 . . . . . . . . . . . . . . . . . . . . . . . . . 4
Note: Adjust lines 5 through 8 to cash method if necessary.
5 Interest received . . . . . . . . . . . . . . . . . . . 5
6 Dividends received and inclusions (Schedule C, line 17) . . . . . . . 6
7
Gross rents, gross royalties, lease income, etc., and gross income from a trade
or business other than an insurance business including income from Form 4797
(include gains for invested assets only) . . . . . . . . . . . .
7
8 Net premiums received . . . . . . . . . . . . . . . . . 8
9 Total. Add lines 5 through 8 . . . . . . . . . . . . . . . . . . . . . . . . . 9
10 Limitation on gross receipts from sales of capital assets. Line 4 less line 9. If zero or less, enter -0- . . . .
10
(a) Description of capital
asset
(b) Date
acquired
(c) Gross
sales price
(d) Cost or
other basis
(e) Expense
of sale
(f) Depreciation allowed
(or allowable)
(g) Loss
((d) plus (e) less
the sum of (c) and (f))
11
12
Totals. Column (c) must not be more than
line 10. (Enter amount from column (g) in
Schedule A, line 28, or Schedule B, line
15, whichever applies.) . . . . .
Schedule H
Special Deduction and Ending Adjusted Surplus for Section 833 Organizations (see instructions)
1 Healthcare claims incurred during the tax year and liabilities incurred during the tax year under cost-plus
contracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
2 Expenses incurred during the tax year in connection with the administration, adjustment, or settlement of
healthcare claims or in connection with the administration of cost-plus contracts . . . . . . . . .
2
3 Total. Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Multiply line 3 by 0.25 . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Beginning adjusted surplus . . . . . . . . . . . . . . . . . . . . . . . . . 5
6
Special deduction. If you checked “No” on line 13 of Schedule I, enter -0- here; you can’t take the special
deduction. All others subtract line 5 from line 4. If zero or less, enter -0-. Enter amount here and on
Schedule A, line 34a. See instructions for limitation . . . . . . . . . . . . . . . . . .
6
7 Net operating loss deduction (Schedule A, line 36b) . . . . . . . . . . . . . . . . . . 7
8 Net exempt income:
a Adjusted tax-exempt income . . . . . . . . . . . . . . . . . . . . . . . . 8a
b Adjusted dividends-received deduction . . . . . . . . . . . . . . . . . . . . . 8b
9 Taxable income (Schedule A, line 37) . . . . . . . . . . . . . . . . . . . . . . 9
10 Ending adjusted surplus. Add lines 5 through 9 . . . . . . . . . . . . . . . . . .
10
Form 1120-PC (2019)
Version A, Cycle 13
INTERNAL USE ONLY
DRAFT AS OF
February 28, 2020
Form 1120-PC (2019)
Page 7
Schedule I Other Information (see instructions)
Yes No
1 Check method of accounting:
a Cash
b
Accrual
c
Other (specify)
▶
2 Check box for kind of company:
a
Mutual
b
Stock
3
At the end of the tax year, did the corporation own,
directly or indirectly, 50% or more of the voting
stock of a domestic corporation? (For rules of
attribution, see section 267(c).) . . . . . .
If “Yes,” attach a statement showing:
(a) name and employer identification number (EIN),
(b) percentage owned, and (c) taxable income or
(loss) before NOL and special deductions of such
corporation for the tax year ending with or within
your tax year.
4 Is the corporation a subsidiary in an affiliated group
or a parent-subsidiary controlled group? . . .
If “Yes,” enter name and EIN of the parent
corporation.
▶
5
At the end of the tax year, did any individual,
partnership, corporation, estate, or trust own, directly
or indirectly, 50% or more of the corporation’s voting
stock? (For rules of attribution, see section 267(c).)
If “Yes,” attach a statement showing name and
identifying number. (Don’t include any information
already entered on line 4 above.)
Enter percentage owned.
▶
6
At any time during the tax year, did one foreign
person own, directly or indirectly, at least 25% of (a)
the total voting power of all classes of stock of the
corporation entitled to vote, or (b) the total value of
all classes of stock of the corporation?. . . .
If “Yes,” enter:
a Percentage owned, and
▶
b Owner’s country.
▶
(c) The corporation may have to file Form 5472,
Information Return of a 25% Foreign-Owned U.S.
Corporation or a Foreign Corporation Engaged in a
U.S. Trade or Business. Enter number of Forms
5472 attached.
▶
Yes No
7 a Enter the total unpaid losses shown on the
corporation’s annual statement:
(1) for the current tax year:
$
(2)
for the previous tax year:
$
b Enter the total unpaid loss adjustment expenses
shown on the corporation’s annual statement:
(1) for the current tax year:
$
(2)
for the previous tax year:
$
8 Does the corporation discount any of the loss
reserves shown on its annual statement? . . .
9 Enter the amount of tax-exempt interest received or
accrued during the tax year:
$
10
If the corporation has an NOL for the tax year
and is electing to forgo the carryback period,
check here . . . . . . . . . .
▶
If the corporation is filing a consolidated return, the
statement required by Regulations section
1.1502-21(b)(3) must be attached or the election
won’t be valid.
11
Enter the available NOL carryover from prior tax
years. (Don’t reduce it by any deduction on
Schedule A, line 36b.) . .
▶
$
12
Is the corporation required to file Schedule UTP
(Form 1120), Uncertain Tax Position Statement?
See instructions . . . . . . . . . .
If “Yes,” complete and attach Schedule UTP.
13
If the corporation is a Blue Cross or Blue Shield
organization described in section 833(c)(2), or other
organization described in section 833(c)(3), did it
meet the medical loss ratio (MLR) requirements of
section 833(c)(5)? . . . . . . . . . .
Enter:
(a) Section 833(c)(5)
MLR numerator . .
▶
$
(b) Section 833(c)(5)
MLR denominator .
▶
$
(c)
Section 833(c)(5) MLR
▶
%
14
If the corporation is a small company as defined in
section 831(b)(2) and elects under section 831(b)(2)
(A)(iii) to be taxed on taxable investment income:
(a) Does the corporation satisfy the diversification
requirements of section 831(b)(2)(B)(i)(l) because no
more than 20% of the net written premiums (or, if
greater, direct written premiums) of the corporation
for the taxable year is attributable to any one
policyholder? . . . . . . . . . . .
(b) If the answer to (a) is “No,” does the corporation
satisfy the diversification requirements of section
831(b)(2)(B)(i)(II)? . . . . . . . . . .
Form 1120-PC (2019)
Version A, Cycle 13
INTERNAL USE ONLY
DRAFT AS OF
February 28, 2020
Form 1120-PC (2019)
Page 8
Schedule I Other Information (see instructions) (continued)
Yes No
15
Does the corporation have gross receipts of at least
$500 million in any of the 3 preceding tax years?
(See section 59A(e)(2) and (3)) . . . . . .
If “Yes,” complete and attach Form 8991.
16
During the tax year, did the corporation pay or
accrue any interest or royalty for which the
deduction is not allowed under section 267A? See
instructions . . . . . . . . . . . .
If “Yes,” enter the total amount of the disallowed
deductions . . . . .
▶
$
Yes No
17
Did the corporation have an election under section
163(j) for any real property trade or business or any
farming business in effect during the taxable year?
See instructions . . . . . . . . . .
18
Is the corporation required to file Form 8990,
Limitation on Business Interest Expense Under
Section 163(j), to calculate the amount of deductible
business interest? See instructions . . . . .
Schedule L
Balance Sheets per Books
Note: All filers are required to complete this schedule.
( ) ( )
( ) ( )
( ) ( )
( ) ( )
( ) ( )
Beginning of tax year End of tax year
Assets
Liabilities and Shareholders’ Equity
Form 1120-PC (2019)
(a) (b) (c) (d)
1 Cash . . . . . . . . . . .
2a Trade notes and accounts receivable . .
b Less allowance for bad debts . . . .
3 Inventories . . . . . . . . . .
4 U.S. Government obligations . . . .
5 Tax-exempt securities (see instructions) .
6 Other current assets (attach statement) .
7 Loans to shareholders . . . . . .
8 Mortgage and real estate loans . . . .
9 Other investments (attach statement) . .
10a Buildings and other depreciable assets .
b Less accumulated depreciation . . . .
11a Depletable assets . . . . . . . .
b Less accumulated depletion . . . . .
12 Land (net of any amortization) . . . .
13a Intangible assets (amortizable only) . .
b Less accumulated amortization . . . .
14 Other assets (attach statement) . . . .
15 Total assets . . . . . . . . .
16 Accounts payable . . . . . . . .
17
Mortgages, notes, bonds payable in less than 1 year
18 Insurance liabilities (see instructions) . .
19 Other current liabilities (attach statement) .
20 Loans from shareholders . . . . . .
21
Mortgages, notes, bonds payable in 1 year or more
22 Other liabilities (attach statement) . . .
23 Capital stock: a Preferred stock . . .
b Common stock . . .
24 Additional paid-in capital . . . . . .
25
Retained earnings—appropriated (attach statement)
26 Retained earnings—unappropriated . .
27
Adjustments to shareholders’ equity (attach statement)
28 Less cost of treasury stock . . . . .
29 Total liabilities and shareholders’ equity
Version A, Cycle 13
INTERNAL USE ONLY
DRAFT AS OF
February 28, 2020
Form 1120-PC (2019)
Page 9
Schedule M-1
Reconciliation of Income (Loss) per Books With Income (Loss) per Return
Note: Schedule M-3 required instead of Schedule M-1 if total assets are $10 million or more. See instructions.
1 Net income (loss) per books . . . . .
2 Federal income tax per books . . . .
3 Excess of capital losses over capital gains
4 Income subject to tax not recorded on
books this year (itemize)
5 Expenses recorded on books this year not
deducted in this return (itemize)
a Depreciation $
b
Charitable contributions $
c
Travel and entertainment $
6 Add lines 1 through 5 . . . . . . .
7 Income recorded on books this year not
included in this return (itemize)
a Tax-exempt interest $
8
Deductions in this tax return not charged
against book income this year (itemize)
a Depreciation $
b
Charitable contributions $
9 Add lines 7 and 8 . . . . . .
10
Income (Schedule A, line 35, or Schedule
B, line 19, if applicable)—line 6 less line 9
Schedule M-2 Analysis of Unappropriated Retained Earnings per Books (line 26, Schedule L)
1 Balance at beginning of year . . . .
2 Net income (loss) per books . . . . .
3 Other increases (itemize)
4 Add lines 1, 2, and 3 . . . . . . .
5 Distributions: a Cash . . . .
b Stock . . . .
c Property . . .
6 Other decreases (itemize)
7 Add lines 5 and 6 . . . . . .
8 Balance at end of year (line 4 less line 7)
Form 1120-PC (2019)
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Form 1120-PC 2019 Insurance Company Income Tax Return

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Completed 10 May 2020

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