2017 ATPA Insurance Assessment

EX-055 (08/2016)
MICHIGAN STATE POLICE
Automobile Theft Prevention Authority

Reporting Period: 2016
Submission Required by: ALL AUTOMOBILE INSURERS
Due Date: 03/31/17 (Private Passenger Vehicles)
Due Date: 05/31/17 (Commercial Motor Vehicles)

Automobile Theft Prevention Authority (ATPA) Annual Assessment

AUTOMOBILE INSURERS: Complete and submit this form online. Do NOT mail any ATPA Insurance Assessment information to the Office of Financial and Insurance Regulation.

COMPANY INFORMATION

Name of Company

Address of Company

City

State

Zip Code

NAIC Group Number

NAIC Company Code

Contact Person Name

Contact Person Title

Contact Person Email Address

Contact Person Phone Number

ASSESSMENT

Total earned car years on all private passenger vehicles insured by your company in 2016 pursuant to MCL 500.3101(1).

Total earned car years on all commercial motor vehicles insured by your company in 2016 pursuant to MCL 500.3101(1).

Multiply total earned car years, as provided above, by $1.00.

*An “Earned Car Year” equals 12 months of insurance coverage on a vehicle. For example, if 12 cars are each insured for one month then the total assessment would be one Earned Car Year. Likewise, if 12 cars are each insured for 12 months then the total would equal 12 Earned Car Years.

If the total of the Earned Car Years equals zero, email a copy of the EXHIBIT OF PREMIUMS AND LOSSES, Statutory Page 14, from your company’s Annual Statement to MSPATPA@michigan.gov (please list company NAIC Group Number in the subject line of the email).

If payment is due, send supporting documentation (summary of the data used to calculate the ATPA Assessment above and the EXHIBIT OF PREMIUMS AND LOSSES, Statutory Page 14, from your company’s Annual Statement) and payment (check made payable to the "State of Michigan") to:
Michigan State Police
c/o ATPA
P.O. Box 30634
Lansing, MI 48909-0634

Certification:
By checking the 'I Certify' button below, you are certifying you have examined this completed form and all the supporting documentation. The information provided on this form and all supporting documentation is a complete, accurate, and true statement of business completeed in Michigan during this reporting year.

I Certify

All questions regarding the Insurance Assessment should be directed to the ATPA at 517-284-3207.

AUTHORITY: MCL 500.6107(1); COMPLIANCE: Mandatory; PENALTY: Suspension, limitation, or revocation of the insurer’s authority to transact insurance in Michigan and/or civil fine.