IG259
2014 Firetown Premium Report
Attachment #2
Informational Report on Fire, Lightning, Sprinkler Leakage and Extended Coverage Premiums
Due March 1, 2015
Check if:
Amended Return
No Activity
Name of Insurance Company
NAIC Number
Minnesota Tax ID (required) State/Country of Incorporation
Note: Numbers in parentheses refer to line numbers on NAIC Minnesota state page. Also include all finance
and service charges.
A
B
C
D
E
Gross Direct Minus
Dividends
Net Premiums
% Fire and
Net Applicable
Return Premiums
Extended
Premiums
(A minus B)
Coverage
(C times D)
1 Fire, lightning and
100%
sprinkler leakage (1) . . . . . . . 1
2 Allied lines
1%
a Crop (2 . 1 ) . . . . . . . . . . . . . 2a
30%
b Other than crop (2 . 1 ) . . . . 2b
3 Multi-peril
35%
a Farmowners (3) . . . . . . . . 3a
35%
b Homeowners (4) . . . . . . . . 3b
c Commercial
55%
nonliability (5 . 1 ) . . . . . . . . 3c
35%
d Commercial liability (5 .2) . 3d
15%
4 Inland marine (9) . . . . . . . . . . 4
15%
5 Earthquake (12) . . . . . . . . . . . 5
10%
6 Aircraft physical damage (22) 6
7 Other fire, lightning, sprinkler
%
leakage, extended coverage . 7
8 Add lines 1 through 7, column E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
No payment due. For informational purposes only.
Attach this report to your Form M11. Keep a copy for your records.