Form Ig258 - Police Premium Report - 2017

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IG258
Attachment #3
2017 Police Premium Report
Informational Report on Auto Insurance Premiums
Due March 1, 2018
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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