Statement Of Premiums For Assessment For Calendar Year 2009
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Statement Of Premiums For Assessment For Calendar Year 2009 Form. This is a New York form and can be use in Department Of Motor Vehicles Statewide.
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Tags: Statement Of Premiums For Assessment For Calendar Year 2009, FM-11, New York Statewide, Department Of Motor Vehicles
New York State Department of Motor Vehicles
6 Empire State Plaza
Expenditure Accounting - Room 120C
Albany NY 12228
STATEMENT OF PREMIUMS FOR ASSESSMENT
FOR CALENDAR YEAR 2010
Total 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 the amounts reported to the State Insurance
Department for their New York Supplemental Insurance Exhibits
lines 19.1, 19.2, 19.5 and 19.6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $)_____________________
Deductions Allowable:
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 authorized by
Section 317 and Section 363 of the Vehicle and Traffic Law. . . . . . . . . . . . . $)_____________________
Name of Company
NAIC Code
Address (Include Number and Street)
Telephone (Area Code)
(
City
State
)
Zip Code
±
Signature of a Principal Officer
Title
State of ____________________________________
County of __________________________________
_______________________________________________________ being duly sworn, says that he/she has read the
foregoing statement and knows the contents thereof and that the same is true to his/her knowledge.
Sworn to me this
________________________ day of _____________________, 20 _________
±
________________________________________________________________
Notary Public
FM-11 (3/11)
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