Member Companies

2023

Form MB0116 Assessable Premium Calculation For Michigan Basic Property

ALL Property & Casualty Insurers must complete this form and submit it to the Michigan Basic Property Insurance Association on or before March 1. Groups must submit a separate form for each company. The information submitted on this form is a statement of each company's Assessable Premiums as defined in Section 2901 (d) of the Michigan Insurance Code.

Companies will be assessed based on the amounts reported. Please read the instructions and notes carefully.
Complete the entire form by filling in all fields.

Company Name

Company Address

Address Line 2

City

State/Province

ZIP/Postal Code

Country

NAIC Company Code

NAIC Group Number

Contact Name

Contact Number

Contact Email Address

Line of Business	Column 1Direct Michigan Premiums written(must agree with page 19, column 1 of annual statement)	Column 2Dividends Paid or Credited(must agree with page 19, column 3 of annual statement. see notes below)	Column 3(see notes below)	Column 4(subtract column 2 and column 3 from column 1)
Fire	Fire Column 1 Total	Fire Column 2 Total	Fire Column 3 Total	Fire Column 4 Total 0
Allied Lines	Allied Lines Column 1 Total	Allied Lines Column 2 Total	Allied Lines Column 3 Total	Allied Lines Column 4 Total 0
Commercial Multiple Peril (Non Liability)	Commercial Column 1 Total	Commercial Column 2 Total	Commercial Column 3 Total	Commercial Column 4 Total 0
Inland Marine	Inland Marine Column 1 Total	Inland Marine Column 2 Total	Inland Marine Column 3 Total	Inland Marine Column 4 Total 0
Burglary and Theft	Burglary Column 1 Total	Burglary Column 2 Total	Burglary Column 3 Total	Burglary Column 4 Total 0
SUB TOTAL Add Column 4 Lines 1-5 ...............				Column 6 Total 0
Homeowners Multiple Peril	Homeowners Column 1 Total	Homeowners Column 2 Total	Homeowners Column 3 Total	Homeowners Column 4 Total 0
GRAND TOTAL Add column 4 Lines 6 and 7 ...............				Column 4 Total 0

Column 2 Only list dividends on premiums included in Column 1.

Column 3 Only list deductions to premiums included in Column 1. The deductions only include premiums on policies covering Michigan farm property and policies covering solely aircraft, watercraft and motor vehicles.

Column 4 Line 6 is the Basic Property Insurance assessable premium.

Column 4 Line 7 is the Home Property Insurance assessable premium.

Column 4 Line 8 is the Aggregate Property assessable premium.

Certification: I have examined this completed form and the information contained in it is complete and correct.

Name

Date

CAPTCHA