Form DL-1
For calendar year 2000 or taxable year beginning
Name of company
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Mailing address
2000 and ending
Federal Identification number
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DOR use only
2000
Massachusetts
Department of
Revenue
Name of treasurer
Has the federal government changed your taxable income for any prior year which has not yet been reported to Massachusetts?
Yes No.
If “Yes,” report such change on Form CA-6, Application for Abatement/Amended Return, within three months after the final federal determination.
Attach a copy of Schedule T of NAIC Annual Statement.
Income and Excise Before Credits
1 1 Taxable life premiums (Part I, line 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ $ ________________ at 2% = . . . . . . . ❿ 1 $
1 2 Net value of policies (Part II, line 12 of Schedule DL-1A). . . . . . . . . . . . . . . . . . ❿ $ ________________ at .25% = . . . . . . ❿ 2
1 3 Applicable measure (line 1 or line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 3
1 4 Taxable accident and health premiums (Part I, line 11) . . . . . . . . . . . . . . . . . . . ❿ $ ________________ at 2% = . . . . . . . ❿ 4
Use whole dollar method
1 5 Total excise due before credits. Add lines 3 and 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Credits
1 6 Enter 1.5% of company’s capital contribution in excess of your full proportionate share in the Massachusetts life insurance company community investment initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 6
1 7 Enter 1.5% of proportionate share of cost of equity securities and outstanding principal balance of debt securities constituting qualified investments of Massachusetts Capital Resource Company (attach computation) . . . . . . . . . ❿ 7
1 8 Enter 10% of Mass. Life and Health Insurance Guaranty Association assessment paid in the prior years (see instructions) ❿ 8
1 9 Economic Opportunity Area Credit (Schedule EOA, line 9). If this credit was claimed on Form DL-2 or Form 176-I, do not claim it on this form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 9
10 Full Employment Credit (Schedule FEC). If this credit was claimed on form DL-2 or Form 176-I, do not claim it here . . . . . ❿ 10
11 Total credits. Add lines 6, 7, 8, 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Excise After Credits
12 Excise due before voluntary contribution. Subtract line 11 from line 5. Not less than “0” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Voluntary contribution for endangered wildlife conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 13
14 Total excise plus voluntary contribution. Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 14
Payments
15 1999 overpayment applied to 2000 estimated tax. . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 15 $
16 2000 Massachusetts estimated tax payments (do not include amount from line 15) ❿ 16
17 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 17
18 Total payments. Add lines 15, 16 and 17. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Refund or Balance Due
19 Amount overpaid. Subtract line 14 from line 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
20 Amount overpaid to be credited to 2001 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . ❿ 20
21 Amount overpaid to be refunded. Subtract line 20 from line 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 21
22 Balance due. Subtract line 18 from line 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
23 M-2220 penalty ❿ $ ______________________ ; Other penalties ❿ $ ______________________ . . . . . . . . Total penalty 23
24 Interest on unpaid balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 24
25 Total payment due at time of filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❿ 25
Under the 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 he/she has knowledge.
Signature of appropriate corporate officer (see instructions) Social Security number Title Date
Individual or firm signature of preparer
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Employer Identification number Address Date
If you are signing as an authorized delegate of the appropriate corporate officer, check here and attach Massachusetts Form M-2848, Power of Attorney.
Mail to: Mass. Department of Revenue, PO Box 7052, Boston, MA 02204. Make check or money order payable to the Commonwealth of Massachusetts.
Form Code 365 Tax Type 0123

Activity for the Year Ending December 31, 2000
1 1 All new and renewal (direct) premiums for Massachusetts residents . . . . . . . . . . . . . . 1 1 ❿ a.
Life insurance
Massachusetts b.
Jurisdictions where no insurance excise paid
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1 2 Dividends applied to: a Purchase paid-up additions . . . . . . . . . . . 1 2a ❿ b Shorten premium paying period. . . . . . . . 1 2b ❿
1 3 Total. Add line 1 through line 2b . . . . . . . . . . . 1 3
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Accident and health insurance c.
Massachusetts d.
Jurisdictions where no insurance excise paid
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Deductions. Include only what has been returned as receipts on this return or on a previous return.
1 4 Returned premiums but not including cash surrender values (attach schedule). . . . . . . . . 1 4 ❿
1 5 Premiums for company employees’ group life and accident and health plans if included in line 1*. . . . . . . . . . . . . . . . . . . . . 1 5 ❿
1 6 Gross premiums for authorized preferred provider arrangements . . . . . . . . . . 1 6 ❿
1 7 Dividends: a Paid in cash . . . . . . . . . . . . . . . . . . . . . . . 1 7a ❿ b Applied in reduction of renewal premiums. . . . . . . . . . . . . . . . . . . . . . . . . 1 7b ❿ c Left to accumulate at interest. . . . . . . . . . 1 7c ❿ d Applied to purchase paid-up additions . . . 1 7d ❿
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❿ e Applied to shorten premium paying period. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 7e ❿
1 8 Total deductions.
Add lines 4 through 7e . . . . . . . . . . . . . . . . . . 1 8
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1 9 Amount taxable.
Subtract line 8 from line 3 . . . . . . . . . . . . . . . . 1 9
10 Total life amount taxable. Add line 9, column A and column B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 $
11 Total accident and health amount taxable. Add line 9, column C and column D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 $
*Premiums under the company employees’ group plans for annuity consideration and retirement benefits shall not be deducted.
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Form DL-1