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3 NEAR FINAL DRAFT 8/1/24 3
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6 *226321* 6
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2024 IG258, Police Premium Report
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10 Informational Report on Auto Insurance Premiums 10
11 Due March 1, 2025 11
12 Check if: Amended Return No Activity Return 12
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13 Name of Insurance Company NAIC Number Minnesota Tax ID (required) State/Country of Incorporation 13
14 NAMEXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 1234567890 12345678900 XXXXXXXXXXXXX 14
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19 Note: Numbers in parentheses refer to line numbers on NAIC Minnesota state page. Also include all finance and 19
20 service charges. 20
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22 1 Gross direct premiums less return premiums on auto insurance coverages 22
23 (lines 19.1–19.4), plus fees, premium finance and other service charges . . . . . . . . . . . . . . . . . . . . . . . . . . 1 12345678900 23
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25 2 Dividends on auto liability insurance coverages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 12345678900 25
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27 3 Net applicable premiums (subtract line 2 from line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 12345678900 27
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29 4 Gross direct premiums less return premiums on auto physical damage 29
30 (lines 21.1 and 21.2), plus policy fees, premium finance 30
31 and other service charges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 12345678900 31
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33 5 Dividends on auto physical damage coverages . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 12345678900 33
34 Premiums for Police State Aid 34
35 6 Net applicable premiums (subtract line 5 from line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 12345678900 35
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37 7 Total applicable premiums (add lines 3 and 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 12345678900 37
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39 No payment due. For informational purposes only . 39
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41 Attach this report to your Form M11. Keep a copy for your records. 41
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44 I declare that this return is correct and complete to the best of my knowledge and belief. 44
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46 Authorized Signature Title Date Daytime Phone 46
I authorize the Minnesota
47 X Department of Revenue to 47
48 SignatureNAMEPreparerof HEREXXXXXXXXXXXPrintNAMEName Preparerof HERE Date12051966Daytime6126781234Phone thisdiscuss tax return with 48
the preparer.
Sign Here
49 NAME HEREXXXXXXXXXXX NAME HERE 12051966 6126781234 49
50 Mail to: 50
51 Minnesota Department of Revenue 51
Mail Station 1780
52 600 N. Robert St. 52
53 St. Paul, MN 55146-1780 53
54 Do not send to the Minnesota Department of Commerce. 54
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