CITY OF TUSCALOOSA POLICE OFFICER’S AND FIREFIGHTER’S RETIREMENT PLAN CERTIFICATE TO BE USED IN REPORTING ALL CATEGORIES OF FIRE INSURANCE WRITTEN FOR THE PURPOSE OF CALCULATING CONTRIBUTIONS DUE THE PLAN

THIS FORM MUST ALSO BE RETURNED EVEN IF NO PAYMENT IS DUE.


Due for all fire insurance coverage issued on property, including mutual and industrial fire insurance
entities: 
(include all lines which insure property against the risk of loss by fire, calculated on the portion of the premium attributed to fire insurance coverage).


Include all gross premiums, including renewals but less return premiums, on policies issued during the preceding year on property located within the City of Tuscaloosa insuring against risk of fire.

Every registered entity that issued a policy must report.

CITY OF TUSCALOOSA POLICE OFFICER’S AND FIREFIGHTER’S RETIREMENT PLAN
PLEASE ENTER THE LEGAL NAME OF THE REPORTING ENTITY AS REGISTERED WITH THE ALABAMA DEPARTMENT OF INSURANCE.

Types of Coverage

Number of policies from which the reported premiums came

Fire/Marine/Boat

Homeowners

Auto Comp.

All Other

The percent of policies allocable fire

Dollar amount of policies / renewals

Total from Above
Total from Above
Total Due @ 1.5%

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Total Due @ 1.5%