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Washington Surveying and Rating Bureau
2101 4TH Avenue Suite 300, Seattle, WA, 98121 | 206.217.9772 | Fax 206.217.9329 | www.wsrb.com | [email protected]
REPORT OF PREMIUMS WRITTEN DURING
FOR:
(Year)
(Company or Group Name)
ANNUAL STATEMENT - Direct Premiums Written - Page 14, Column 1
ENTER ENTIRE AMOUNT - TO NEAREST DOLLAR
Fire
Allied Lines
Farmowners
Homeowners
Commercial Multi-Peril
* Non-Liability
(Line 1)
(Line 2.1)
(Line 3)
(Line 4)
(Line 5.1)
$
$
$
$
$
(NAIC #)
Earthquake
Total
(Line 12)
(Lines 1-5, 12)
$
This Total must match
the TOTAL shown
below
$
* Non-Liability is considered Property - Fire and Allied Lines
In the following area, please enter accordingly, the premiums shown in ANNUAL STATEMENT above -ENTER ENTIRE AMOUNT - TO NEAREST DOLLAR
DIRECT PREMIUMS WRITTEN
LINES OF BUSINESS
Direct Premiums Written
Reserved for Bureau Use
Line 1 - Fire
DWELLING PROPERTY
$
FARM PROPERTY
$
COMMERICAL PROPERTY
$
Line 2.1 - Allied Lines
DWELLING PROPERTY
$
FARM PROPERTY
$
COMMERICAL PROPERTY
$
Line 3
FARMOWNERS
$
Line 4
HOMEOWNERS
$
Line 5.1 - Commercial Multi-Peril - Non Liability
ENTER PROPERTY PREMIUMS ONLY
COMMERCIAL PACKAGE
(include Market Segments Programs & Businessowner Policies)
$
Line 12 - Earthquake
COMMERCIAL
$
PERSONAL
$
Total Premiums Reported $
LIST ANY PREMIUMS SHOWN
IN ANNUAL STATEMENT AND
NOT REPORTED ABOVE
Capital Assets:
$
Agricultural Capital Assets:
$
*Other (Identify):
$
*Other (Identify):
$
*Other (Identify):
$
TOTAL
$
NAME
TITLE
EMAIL
ADDRESS OF PREPARER
See attached --
This TOTAL must match the Total shown in
ANNUAL STATEMENT above
DATE
TELEPHONE NUMBER
FAX NUMBER
For Member Companies to be included in this report; To update Contact and/or Member information.
Attachment D
Page 1
1-31-13
INSTRUCTIONS
Companies under common management may submit a combined premium report. If, however, any company in the group differs from
the others as to Bureau services received, then separate reports must be submitted for the differing companies.
ANNUAL STATEMENT PREMIUMS
Report Annual Statement premiums from column 1 of your Statutory Page 14, in the space provided. The total of these premiums
should equal the Total of Direct Written Premiums.
DIRECT PREMIUMS WRITTEN
Enter Full Premiums - TO THE NEAREST DOLLAR
Report all gross premiums written less cancellations and returns.
Do not deduct dividends or participation to policyholders from the premiums reported.
Include the company's share of premiums obtained from associations, pool arrangements or jointly operated underwriting agencies.
Exclude premiums obtained from Railroad Property, the Cotton Insurance Association or the Cotton Fire and Marine Underwriters
LINES OF BUSINESS
Annual Statement Line 1 includes premiums for Commercial property, Dwelling property and Farm property.
Please designate individually, on this report » Premiums written under the Dwelling program
» Premiums written under the Farm program
» Premiums written under Division 5, Commercial Property
Annual Statement Line 2.1 includes premiums for Commercial property, Dwelling property and Farm property
Please designate individually, on this report » Premiums written under the Dwelling program
» Premiums written under the Farm program
» Premiums written under Division 5, Commercial Property
Annual Statement Line 3 includes premiums written under the Farmowners program only.
Annual Statement Line 4 includes premiums written under the Homeowner program only.
Annual Statement Line 5.1 includes the property portion only of Commercial Multi-Peril policies.
Please include on this report, the premiums that are Commercial Package policies (including Market Segments
Programs) and the premiums that are Businessowners policies.
Enter property premiums only.
Annual Statement Line 12 includes earthquake premiums written as commercial lines and earthquake premiums written as
personal lines (dwelling property and farm property)
Please designate individually, on this report » Premiums written under Division 5, Commercial Property
» Premiums written under Personal lines property
PREMIUMS NOT REPORTED ABOVE
Report here all property premiums that have not been included in the Lines of Business section of this Premium Report form because
they use NO WSRB loss costs, rules or forms, but do appear in the Annual Statement on page 14, Column 1, lines 1 to 5 plus 12. List
and explain premiums individually in the spaces provided.
THE TOTAL OF THE ANNUAL STATEMENT MUST EQUAL THE TOTAL OF THE LINES OF BUSINESS.
COMPANIES WE CURRENTLY SHOW AS MEMBERS TO BE INCLUDED IN YOUR WSRB SUBSCRIPTION:
(Please note any changes to the Member Companies shown)
NAIC #
Member Company
COMPANY INFORMATION - Please update your company's main mailing address and contact:
Street Address:
Suite / PO Box:
City, State, Zip:
Main Phone #:
Main Fax #:
Main Email Address:
Main Company Contact Person:
(Official or representative in principal charge of supervision of business written in the State of Washington to whom we shall send all
official communications.)
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