Form Ig258 - Police Premium Report - Minnesota Department Of Revenue - 2013
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2IG258
2013 Police Premium Report
Attachment #3
Informational Report on Auto Insurance Premiums
Due March 1, 2014
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.
1 Gross direct premiums less return premiums on auto insurance coverages
(lines 19.1–19.4), plus fees, premium finance and other service charges . . . . . . . . . . . . . . . . . . . . . . 1
2 Dividends on auto liability insurance coverages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Net applicable premiums (subtract line 2 from line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Gross direct premiums less return premiums on auto physical damage
(lines 21.1 and 21.2), plus policy fees, premium finance
and other service charges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Dividends on auto physical damage coverages . . . . . . . . . . . . . . . . . . . . . . . 5
6 Net applicable premiums (subtract line 5 from line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7 Total applicable premiums (add lines 3 and 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
No payment due. For informational purposes only .
Attach this report to your Form M11. Keep a copy for your records.
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Parent category: Financial