Statement of Premiums for Assessment for Calendar Year 2020 (FM-11)

 

INSTRUCTIONS

Complete your statement for the past calendar year (2020). We will email you a confirmation that includes a summary of the information you provide.

 

TOTAL OF GROSS DIRECT PREMIUMS

Less return premiums thereon, for policies or contracts of private passenger and commercial automobile bodily injury insurance. This amount should agree with the sum of NY Supplemental Insurance Exhibits lines 19.1, 19.2, 19.5 and 19.6.

$

 

DEDUCTIONS ALLOWED

Gross direct premiums less return premiums thereon, for policies or contracts of which evidence thereof has been filed under Section 370 of the Vehicle and Traffic Law.

$

Other state automobile bodily Injury risks reported to New York State for tax purposes only. (Do not enter amount on this line unless included in your Total Gross Direct Premiums reported above.)

$


TOTAL DEDUCTIONS

$

 

FINAL TOTAL FOR ASSESSMENT

Final Total for Assessment Authorized by Section 137 and Section 363 of the Vehicle & Traffic Law.

$

 

COMPANY INFORMATION

NAIC Code

Company Name

Address

City

State

ZIP Code

Contact Person

Phone

 

CERTIFICATION

Certification: *