Fillable Form Ig259 - Firetown Premium Report

Form Ig259 - Firetown Premium Report - 2017

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IG259

Attachment #2

2017 Firetown Premium Report

Informational Report on Fire, Lightning, Sprinkler Leakage and Extended Coverage Premiums

Due March 1, 2018

Check if:

Amended Return

No Activity

Minnesota Tax ID (required)

Name of Insurance Company

NAIC Number

State/Country of Incorporation

Note: Numbers in parentheses refer to line numbers on NAIC Minnesota state page. Also include all finance and

service charges.

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

sprinkler leakage (1) . . . . . . . . 1

100%

2 Allied lines

a Crop (2 .1) . . . . . . . . . . . . . . 2a

30%

b Other than crop (2 .1) . . . . 2b

3 Multi-peril

35%

a Farmowners (3) . . . . . . . . . 3a

b Homeowners (4) . . . . . . . . 3b

35%

c Commercial

55%

nonliability (5 .1) . . . . . . . . . 3c

35%

d Commercial liability (5 .2) . 3d

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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No payment due. For informational purposes only.

Attach this report to your Form M11. Keep a copy for your records.