Form Ig255 - Nonadmitted Insurance Premium Tax Return For Direct Procured Insurance - 2017 Page 2

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IG255
Page 2
2017 Nonadmitted Insurance Premium Tax Return for Direct Procured Insurance
Name of insured
Minnesota tax ID number
List all policies where Minnesota is the home state of the Insured.
A
B
C
D
E
F
G
H
NAIC
Date of Coverage
Insurance
Amount
Gross
Return
Number
Name of Insurer
Policy Number
(from _____ to _____)
Type Code*
Insured
Premiums Paid
Premiums
Subtotal
(if more than one page)
Total
* Use one of the following code numbers to indicate the insurance type.
1 Fire
3 Homeowners/Commercial M.P.
5 Accident/Health
7 Auto
9
Burglary/Theft
11 Other (specify)
2 Extended coverage/Allied lines
4 Inland/Ocean marine
6 Liability
8 Fidelity/Surety
10 Boiler/Machinery

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