Form Ig262 - Fire Safety Surcharge Return For Mutual Companies - 2017
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3IG262
2017 Fire Safety Surcharge Return for Mutual Companies
For the period of (check one):
Jan. 1 – March 31, 2017
April 1 – June 30, 2017
July 1 – Sept. 30, 2017
Oct. 1 – Dec. 31, 2017
(Due May 15)
(Due Aug. 15)
(Due Nov. 15)
(Due Feb. 15, 2018)
Check if:
Amended Return
No Activity Return
Name of Insurance Company
FEIN
Minnesota Tax ID (required)
Mailing Address
Check if New Address
NAIC Number
State/Country of Incorporation
City
State
Zip Code
Contact Person
Email Address
Website Address
Daytime Phone
Fax Number
Note: Numbers in parentheses refer to line
A
B
C
D
E
numbers on NAIC Minnesota state page. Also
Total Direct
Dividends
Net Direct
% of
Minnesota
Premiums
Premiums
Fire
Basis
include all finance and service charges.
(A minus B)
(C times D)
100%
1 Fire (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
55%
c Commercial nonliability (5.1) . . . . . . 3c
35%
d Commercial liability (5.2) . . . . . . . . 3d
15%
4 Inland marine (9) . . . . . . . . . . . . . . . 4
15%
5 Ocean marine (8) . . . . . . . . . . . . . . . 5
15%
6 Earthquake (12) . . . . . . . . . . . . . . . 6
7 Auto physical damage (21 . 1 -21 .2) (total com-
mercial and private) or itemize combined auto
7%
comprehensive fire premiums (lines 7a-7f) . 7
a Comprehensive fire, theft and
19%
miscellaneous (exclude collision) . . . . 7a
b Comprehensive fire, theft and miscellane-
35%
ous with deductible (exclude collision)
7b
75%
c Fire and theft combined . . . . . . . . . 7c
50%
d Fire, theft and miscellaneous . . . . . . 7d
100%
e Fire . . . . . . . . . . . . . . . . . . . . 7e
%
f Collision and others . . . . . . . . . . . 7f
10%
8 Aircraft physical damage (22) . . . . . . . . 8
%
9 Other fire (itemize on a separate schedule) . 9
10 Taxable fire premiums (add lines 1 through 9, column E) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
.005
11 Surcharge rate (0.5%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Fire insurance surcharge liability (multiply line 10 by the rate on line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Penalty (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
14 Interest (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
15 TOTAL AMOUNT DUE (or overpaid) (add lines 12 through 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
If you owe additional tax (make separate payments for each period):
Payment method:
Electronic payment
Check
(payable to Minnesota Revenue; write MN tax ID number on check; attach voucher
)
Enter amount paid
Date paid
(If amount paid is different from line 15, attach an explanation.)
If you overpaid: Overpayments will be refunded .
I declare that this return is correct and complete to the best of my knowledge and belief.
Authorized signature
Title
Date
Daytime phone
I authorize the
Minnesota Department
of Revenue to discuss
Signature of preparer
Print name of preparer
Date
Daytime phone
this tax return with the
preparer .
Mail to: Minnesota Revenue, P.O. Box 1780, St. Paul, MN 55145-1780
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Parent category: Financial