Submission Required By:
MICHIGAN ASSIGNED CLAIMS PLAN
PROPERTY & CASUALTY INSURERS WITH
Maintained by the Michigan Automobile
EXCEPTION PREMIUM TO REPORT
Insurance Placement Facility
Read instructions below
PO Box 532318 Livonia, MI 48153
NOTE: IF YOU DO NOT HAVE EXCEPTION PREMIUM TO REPORT, DO NOT SUBMIT THIS FORM.
Please file this form if your company has snowmobile and/or motorcycle premiums reported on the Annual Statement for
You must also include supporting documentation (a company report, written explanation, or other
source) which validates the amount of exception premium being claimed.
All Property and Casualty Insurers: Companies will be assessed based on the amount of direct premiums reported to the
NAIC and the Department of Insurance and Financial Services (DIFS) on the company’s annual statement. Surplus Lines
Insurers will not be assessed.
Groups: Submit a separate form for each company having a separate NAIC company code.
Self-Insurers: Companies with an approved 2016 Certificate of Self-Insurance from the Department of Insurance and
Financial Services (DIFS) should NOT submit this form for their self-insured writings.
The amount of snowmobile and motorcycle premiums you report on this form will be deducted from assessable premiums
for purposes of the assessment for the Michigan Assigned Claims Plan.
Use this form to report the amount of snowmobile and motorcycle premiums included in your annual statement (Exhibit
of Premiums and Losses, Business in the State of Michigan), column 1 Direct Premiums Written (total of lines 19.1 through
Submit completed forms directly to MAIPF via e-mail as indicated below. The form must be received by MAIPF no later
than March 1, 2017. Assessable premiums will not be adjusted for late or missing forms.
NOTE: IF YOU DO NOT HAVE EXCEPTION PREMIUM TO REPORT, DO NOT SUBMIT THIS FORM. DO NOT REPORT IF $0
Enter snowmobile and motorcycle premiums included in lines 19.1 through 19.4 of
the Annual Statement for Michigan (use whole dollar amounts)
NAIC Group Number
City, State, Zip
Please scan and return completed form to MAIPF
via e-mail no later than 3/1/2017
I have examined this completed form and the information
contained in it is complete and correct.
Send completed form
and supporting documentation
the following e-mail address:
to be used for exception form
reporting only and not for general correspondence.
Signers name and title, typed or printed