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3 NEAR FINAL DRAFT 8/1/24 3
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6 *226331* 6
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2024 IG259, Fire Premium Report
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10 Informational Report on Fire, Lightning, Sprinkler Leakage and Extended Coverage Premiums 10
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Due March 1, 2025
12 Check if: X Amended Return No Activity Return 12
X
13 Name of Insurance Company NAIC Number Minnesota Tax ID (required) State/Country of Incorporation 13
14 NAMEXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 12345678900 12345678900 XXXXXXXXXXXXX 14
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17 Numbers in parentheses refer to line numbers on NAIC Minnesota state page. Also include all finance and 17
Note:
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service charges.
19 A B C D E 19
20 Gross Direct Minus Dividends Net Premiums % Fire and Net Applicable 20
21 Return Premiums (A minus B) Extended Premiums 21
Coverage (C times D)
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23 1 Fire, lightning and 23
24 sprinkler leakage (1) . . . . . . . . 1 1234567890 1234567890 1234567890 100% 123456789024
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26 2 Allied lines 26
27 a Crop (2 .1) . . . . . . . . . . . . . . 2a 1234567890 1234567890 1234567890 1% 123456789027
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29 b Other than crop (2 .1) . . . . 2b 1234567890 1234567890 1234567890 30% 123456789029
30 30
31 3 Multi-peril 31
32 a Farmowners (3) . . . . . . . . . 3a 1234567890 1234567890 1234567890 35% 123456789032
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34 b Homeowners (4) . . . . . . . . 3b 1234567890 1234567890 1234567890 35% 123456789034
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36 c Commercial 36
37 nonliability (5 .1) . . . . . . . . . 3c 1234567890 1234567890 1234567890 55% 123456789037
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39 d Commercial liability (5 .2) . 3d 1234567890 1234567890 1234567890 35% 123456789039
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41 Premiums for Fire State Aid 4 Inland marine (9) . . . . . . . . . . . 4 15% 41
1234567890 1234567890 1234567890 1234567890
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43 5 Earthquake (12) . . . . . . . . . . . . 5 1234567890 1234567890 1234567890 15% 123456789043
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45 6 Aircraft physical damage (22) . 6 1234567890 1234567890 1234567890 10% 123456789045
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47 7 Other fire, lightning, sprinkler 47
48 leakage, extended coverage . . 7 1234567890 1234567890 1234567890 % 123456789048
49 49
50 8 Add lines 1 through 7, 50
51 column E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8123456789051
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53 No payment For informationaldue. purposes only. 53
54 Attach this report to your Form M11. Keep a copy for your records. 54
55 I declare that this return is correct and complete to the best of my knowledge and belief. 55
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57 Authorized Signature Title Date Daytime Phone 57
X I authorize the Minnesota
58 Department of Revenue to 58
59 SignatureNAMEPreparerof HEREXXXXXXXXXXNAMEPrint Name Preparerof HERE 12051966Date Daytime6126781234Phone discuss this tax return with 59
the preparer .
Sign Here
60 NAME HEREXXXXXXXXXX NAME HERE 12051966 6126781234 60
61 Mail to: Minnesota Department of Revenue, Mail Station 1780, 600 N. Robert St., St. Paul, MN 55146-1780. 61
62 Do not send to the Minnesota Department of Commerce . 62
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