BLANK FORM OF ANNUAL STATEMENT
OF
MUTUAL FIRE INSURANCE COMPANIES
CONTAINING
KEY TO STATISTICAL TABLES BY NUMBERS
CITY AND VILLAGE MUTUALS.
BALANCE SHEET
Amount of ledger assets (as per balance) December 31 of previous year
INCOME
1.  Gross premiums on all business written during the year ...............
2.  Assessments actually received on current year's assessments .........
I . Assessments actually received on previous years' assessments.
4*   *Policy fees: .... New, No .......   ; fee, $ ....... ; amount $   .
5.  Renewels: .......... No. ....... ; fee, $........ ; amount, $      .
6.  Additions :.   ........ No ..- ; fee, $.              ; amount $
7.           Total policy fees .
8.           Total collections .......       ..............
Deduct:
9.  Paid for reinsurance ...............................................
10.  Returned on cancellations ....................................
11.  Returned   in dividends.      ...................................
12.           Total deductions ...........................
13.  Total premiums and assessments, less deductions ......................
14.  Cash received as interest ........                      ......... ..
15.   Cash received as borrowed money (date borrowed, ...... '. .) .
16.  Cash received from all other sources, viz.: (Itemize)
17 .   ................  ..........  A................  ...... . . ..   .
18 .   . ......  . ...  ...............  .. ....... ................
19.           Total income during year     .............
20.   Total assets of previous year and income .....................   ......
DISBURSEMENTS
1.  Paid for losses including E .... .... for losses occurring in previous
years.
2. Agents' balances charged off ....................................J
3.  Paid for fire department taxes .....................................
4.  Paid for fire marshal taxes ..........................................
5.  Paid for corporation tax ............................................
6.   Borrowed money tdate repaid ........)...........................)
7.   Interest on borrowed money ..............................     \    .-
S.   Salaries, $ ........  and fees, $ ........ I paid officials .