NEAR FINAL DRAFT 8/1/24

                                                                                                                                                                                                             *226321*

2024 IG258, Police Premium Report

Informational Report on Auto Insurance Premiums
Due March 1, 2025
                                                                                                                       Check if:                                                              Amended Return               No Activity Return 
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 
                             Premiums for Police State Aid
                                                            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.

                                                          I declare that this return is correct and complete to the best of my knowledge and belief.  
                                                          Authorized Signature           Title                                   Date                                                        Daytime Phone
                                                                                                                                                                                                                           I authorize the Minnesota 
                                                                                                                                                                                                                          Department of Revenue to 
                                                          Signature of Preparer          Print Name of Preparer                  Date                                                        Daytime Phone                discuss this tax return with 
                                                                                                                                                                                                                          the preparer.
         Sign Here
                                                          Mail to: 
                                                          Minnesota Department of Revenue
                                                          Mail Station 1780
                                                          600 N. Robert St.
                                                          St. Paul, MN 55146-1780
                                                          Do not send to the Minnesota Department of Commerce.