Form 1120-L U.S. Life Insurance Company Income Tax Return

U.S. Life Insurance Company Income Tax Return (Form 1120-L)

Department of the Treasury

Internal Revenue Service

For calendar year 2016 or tax year beginning , 2016, ending , 20

▶ Information about Form 1120-L and its separate instructions is at www.irs.gov/form1120l.

Please print or type

Name

Number, street, and room or suite no.

City or town, state or province, country, and ZIP or foreign postal code

B Employer identification number

C Date incorporated

A Check if:

Consolidated return (attach Form 851)

Life-nonlife consolidated return

Schedule M-3 (Form 1120-L) attached

D Check applicable box if an election has been made under section(s):

E Check if:

(1) Final return

(2) Name change

(3) Address change

(4) Amended return

Sign Here

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 EIN

Firm's address

Phone no.

Income

1 Gross premiums, etc.

2 Net decrease in reserves

3 10% of any decrease in reserves

4 Investment income

5 Net capital gain

6 Income from a special loss discount account

7 Other income

8 Life insurance company gross income

Deductions

9 Death benefits, etc.

10 Net increase in reserves

11 10% of any increase in reserves

12 Deductible policyholder dividends

13 Assumption of liabilities

14 Dividends reimbursable by taxpayer

15a Interest b Less tax-exempt interest expense c Bal

16 Deductible policy acquisition expenses

17 Additional deduction

18 Other deductions

19 Add lines 9 through 18

20 Subtotal

21a Dividends-received deduction b Operations loss deduction c Total

22 Gain or (loss) from operations

23 Small life insurance company deduction

24 Life insurance company taxable income

25 Limitation on noninsurance losses

26 Amount subtracted from policyholders surplus account

Tax and Payments

27 Taxable income

28 Total tax

29a 2015 overpayment credited to 2016

29b Prior year special estimated tax payments

29c 2016 estimated tax payments

29d 2016 special estimated tax payments

29e Less 2016 refund applied for on Form 4466

29f Total

29g Tax deposited with Form 7004

29h Credits (Form 2439 / Form 4136)

29i U.S. income tax paid or withheld at source

29j Refundable credit from Form 8827

29k Total credits

30 Estimated tax penalty Check if Form 2220 is attached

31 Amount owed

32 Overpayment

33 Enter amount from line 32: Credited to 2017 estimated tax Refunded

Schedule M - Other Information

1 Check method of accounting: Accrual Other (specify)

2 Check if the corporation is a: Legal reserve company Fraternal or assessment association Burial or other insurance company

Kind of company: Stock Mutual

Principal business: Life Insurance Health and accident insurance

3 Percentage of reserves

4 Variable annuity contracts outstanding? Yes No

5 Ownership of voting stock by domestic corporation? Yes No

6 Subsidiary in affiliated group or parent-subsidiary controlled group? Yes No

7 Any 50% or more ownership by individual, partnership, corporation, estate, or trust? Yes No

7a Name and identifying number

7b Percentage owned

8 Foreign person 25% ownership? Yes No

8a Percentage owned

8b Owner’s country

8c Number of Forms 5472 attached

9 Own payout pattern for discounting unpaid losses? Yes No

10 Discount any loss reserves shown? Yes No

11a Total unpaid losses current year

11a Total unpaid losses previous year

11b Total unpaid loss adjustment expenses current year

11b Total unpaid loss adjustment expenses previous year

12 Operations loss deduction election? Check here

13 Available OLD carryover from prior tax years

14a State of domicile

14b Annual statement filed with state of domicile? Yes No

14c State where annual statement was filed

15 Required to file Schedule UTP? Yes No