Form Ig260 - Nonadmitted Insurance Premium Tax Return For Surplus Lines Brokers - Minnesota Department Of Revenue - 2013 Page 2

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IG260
page 2
2013 Nonadmitted Insurance Premium Tax Return for Surplus Lines Brokers
(continued)
A
B
C
D
E
F
G
H
I
J
NAIC
Effective Date
Trans.
Total
All Fees/
Total Gross
Return
Number
Name of Insurer
Policy Number
(required)
Name of Insured
Type*
Premiums
Commissions
Premiums (G + H)
Premiums
* See “Page 2, Column instructions” for a list of codes to enter
Subtotal (if more than one page) . . . . . . . . . . .
in column F.
Total Pre-NRRA and Post-NRRA.
Enter on appropriate lines on page 1 . . . . . . . .

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