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2012 ANNUAL RENEWAL FORM FOR THE CITY OF MOBILE, ALABAMA

POLICEMEN AND FIREFIGHTERS PENSION AND RELIEF FUND

CERTIFICATE TO BE USED IN REPORTING ALL CATEGORIES OF FIRE INSURANCE WRITTEN FOR THE PURPOSE

OF CALCULATING CONTRIBUTIONS TO THE POLICEMEN'S & FIREFIGHTER'S PENSION AND RELIEF FUND

Include in the certificate the following:

Fire Insurance On Property: (include all lines which insure property against the risk of loss by fire,

calculated on the portion of the premium attributable to fire insurance coverage).

Gross premiums, less return premiums, including renewal premiums, on policies issued during the preceding

year on property located within the City of Mobile AND its Police Jurisdiction insuring against risk of fire.

( A )

( B )

( C )

( D )

( E )

TYPES OF

FIRE %

TOTAL NEW

% FIRE PREMIUM

TOTAL RENEWAL

% FIRE PREMIUM

COVERAGE:

PREMIUMS

( A x B)

PREMIUMS

( A x D )

Fire/Marine/Boat __1 0 0__ % __$ 15,000.00_______ [___$ 15,000.00____] _______$ 6,000.00____ {____$ 6,000.00___}

Homeowners

____20___% __$ 11,000.00_______ [_____ 2,200.00____] ________ 3,000.00____ {_______600.00___}

Auto Comp.

____15___% __$ 3,500.00_______ [_______525.00_____] _________500.00____ {________75.00____}

All Other

_____2___% __$ 2,500.00_______ [________50.00_____] ________2,500.00____ {________50.00____}

TOTALS FROM ABOVE:

[(C)__$ 17,775.00____]

{(E) ____$ 6,725.00___}

Amount of NEW PREMIUMS collected during 2011-[(C)]:

$ ____$ 17,775.00___ @ 2 % = ___$ 355.50___

Amount of RENEWAL PREMIUMS collected during 2011-{(E)}:

$ ____$ 6,725.00___ @ 2 % = ___$ 134.50___

TOTAL: ___$ 490.00___

AFFIDAVIT: State of ____________________, County of____________________ I, _________________________________, am duly

authorized to make this certificate for: Name of Company:_______________________________________________________________

Mailing Address:________________________________________City:________________________State:______Zip:___________

And I do hereby certify under oath that the amounts shown above are the total amount of premium revenue as defined above and collected

in 2011 on policies issued by said company on business written by each agent or representative of the Company, and that there have been

no deductions for reinsurance or dividends paid.

BY: _____________________________________________________ TITLE: _______________________

Enclose check with completed affidavit to:

Mobile Policemen's and Firefighter's Pension Fund

Attn: Pension Fund Collection Center

Post Office Box 3065

Mobile, Alabama 36652-3065

Policemen And Firefighters Pension And Relief Fund Annual Renewal Form - Cityy Of Mobile, Alabama

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