NEAR FINAL DRAFT 8/1/24

                                                                                                                                                           *226331*

2024 IG259, Fire Premium Report

Informational Report on Fire, Lightning, Sprinkler Leakage and Extended Coverage 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.
                                                                                                         A                B                C                  D                                                                                                E
                                                                                                  Gross Direct Minus      Dividends        Net Premiums    % Fire and                                                                                          Net Applicable 
                                                                                                   Return Premiums                         (A minus B)     Extended                                                                                            Premiums
                                                                                                                                                           Coverage                                                                                            (C times D)

                                              1  Fire, lightning and 
                                                sprinkler leakage (1)   . . . .  . . . .  1                                                                100%         

                                              2  Allied lines
                                                a  Crop (2 .1)   . . .  . . . . . .  . . . . .  2a                                                            1%        

                                                b  Other than crop (2 .1)    . . . .  2b                                                                   30%          

                                              3 Multi-peril
                                                a  Farmowners (3)   . . . . . .  . . .  3a                                                                 35%          

                                                b  Homeowners (4)   . . . .  . . . .  3b                                                                   35%          

                                                c  Commercial 
                                                 nonliability (5 .1)  . . .  . . . . . .  3c                                                               55%          

                                                d  Commercial liability (5 .2)   .  3d                                                                     35%          

                  Premiums for Fire State Aid 4 Inland marine (9)   . . .  . . . . . .  . .  4                                                             15%          

                                              5  Earthquake (12)   . . .  . . . . . .  . . .  5                                                            15%          

                                              6 Aircraft physical damage (22)    .  6                                                                      10%          

                                              7  Other fire, lightning, sprinkler 
                                                leakage, extended coverage   .  .  7                                                                                 %  

                                              8  Add lines 1 through 7,  
                                                column E  . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . .  . . . . . .  . . . . . .  . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . . .  . . . . . .  . . 8

                                               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 .