Form Fprf - Annual Report Of Premiums And Taxes For Property And Casualty Insures For The Fprf Premium Tax Fund - 2011 Page 3

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NAIC______
COMPANY NAME________________________________
2011 FORM AID AC FPRF
100% of Premium Written for Arkansas coverages on real and personal property
as reported by line of business on the 2011 Arkansas State Page:
0.00
1
Fire
$
0.00
2.1
Allied Lines
$
0.00
2.2
Multiple Peril Crop
$
0.00
3
Farm Owners Multiple Peril
$
0.00
4
Homeowners Multiple Peril
$
0.00
5.1
Commercial Multiple Peril (non liability)
$
0.00
8
Ocean Marine
$
0.00
9
Inland Marine
$
0.00
12
Earthquake
$
0.00
21.1
Private Passenger Auto Physical Damage
$
0.00
21.2
Commercial Auto Physical Damage
$
0.00
22
Aircraft – all perils
$
0.00
26
Burglary and Theft
$
0.00
27
Boiler and Machinery
$
0.00
30
Warranty
$
0.00
34
Aggregate Write in for Other Lines of Business
$
0.00
TOTAL – Page 1, Line 1
$
A
FFIDAVIT
State of _______________________
County of ______________________
Comes_______________________________________________________________________ and states on oath that he/she is the
__________________________________________ of _________________________________________________________________
(Title)
(Name of Company)
and that the foregoing statements are true and correct as shown by the records of said Company.
__________________________________________________
(Original Signature of Officer)
Subscribed and sworn to or affirmed before me, the undersigned Notary Public, on this the ______ day of ______________, 20_____.
_____________________________________
NOTARY PUBLIC
My Commission Expires_____________________________________
ARKANSAS INSURANCE DEPARTMENT
Page 2 of 2
REVISED 2011
FEDERAL TAX ID NUMBER 71-0847443

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