Form Ins-5 - Fire Investigation And Prevention Tax - 2002
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1
2*023110000*
FORM INS-5
FIRE INVESTIGATION
AND PREVENTION TAX
ANNUAL/RECONCILIATION RETURN
Account ID No.
Period Begin
Period End
Due Date
COMPUTATION OF TAX ON FIRE PREMIUMS
1
2
3
4
5
,
,
$
.00
,
,
$
.00
,
,
$
.00
Auto Physical Damage:
Comprehensive – Full Coverage
(covers 001, 004, 061, etc.)
$
,
,
.00
$
.00
,
,
Comprehensive – All Deductibles:
(covers 003, 005, 010, 062, 065, etc.)
,
,
$
.00
,
,
$
.00
Fire and Theft:
(covers 012, 033)
,
,
.00
$
,
,
.00
$
Fire, Theft and Misc.:
(covers 020, 021, 031, 034, 035, 036, etc.)
$
,
,
.00
$
,
,
.00
$
,
,
.00
$
,
,
.00
$
,
,
.00
Any Others
,
,
$
.00
1. Total of amounts entered in column 5 ....................................................................................... ............................................... 1.
INS-5 Rev. 10/02
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