1782

THE NEW ZEALAND GAZETTE.

[No. 54

Form C.

Fire Insurance, 19

[F.I. No. 1.

STATISTICAL RETURN FOR THE YEAR ENDED

(To be made out for the financial year of the company most closely approximating the calendar year 19.)

Name in full of Office:
Address of Head Office:
Postal address of Head Office for New Zealand:

I.-As to Position at End of Year.
(To refer to all departments of business underwritten.)

Liabilities (New Zealand and elsewhere)--

1. Paid-up capital .. .. .. .. .. .. .. ..
2. Reserves .. .. .. .. .. .. .. ..
   (Excluding paid-up capital, but including undivided profits.)
3. Other liabilities .. .. .. .. .. .. .. ..
   (Excluding 1 and 2 above, but inclusive of debenture stocks.)
4. Total of items 1, 2, and 3 .. .. .. .. .. .. ..
5. Life Department funds .. .. .. .. .. .. ..
6. Total of items 4 and 5
   (This should agree with the total liabilities for which the balance-sheet shows corresponding assets.)

New Zealand assets--
7. House and landed property in New Zealand owned by the office .. .. .. ..
8.) New Zealand Government securities : { Ordinary .. .. ..
9.) { War Loan .. .. .. ..
10. New Zealand local authority securities .. .. .. ..
11. Mortgages on freehold and leasehold security in New Zealand .. .. ..
Miscellaneous, as follows:-
12. Cash in hand or at bank .. .. .. .. £
13. Cash deposited with Public Trustee .. .. .. .. £
14. Outstanding premiums .. .. .. .. .. .. £
15. Sundry debtors .. .. .. .. .. .. £
16. Other (specify): .. .. .. .. .. .. £
17. Total New Zealand assets .. .. .. .. .. .. £

II. As to Fire Business.

18. Total gross amount of insurance cover in force in New Zealand on 3lst December last, excluding reinsurances accepted from other offices .. .. .. .. No.
19. Total gross amount of New Zealand business (new and renewal) underwritten during year, excluding reinsurances accepted from other offices .. .. .. .. No.
20. Total gross premiums charged for underwriting the amount shown under preceding question No. 19 ..
21. Total amount of premiums refunded to insured .. .. .. .. .. ..
    (Refunds to other insurances offices are not to be included.)
22. Number of separate outbreaks of fire with which concerned, as per detailed list as required on Form "D" (i.e., not the number of separate claims paid but the number of separate fires in respect of which claims paid) .. .. .. .. .. .. .. .. No.

III. Revenue Account.--New Zealand Business for Financial Year ended
(The items to be entered here are those applicable to the New Zealand fire business only. In the event of any allocation being made on an arbitrary basis this fact should be stated, in the form of a marginal note.)

(a.) Expenditure.
Net amount of fire losses incurred during year, including adjustment and other expenses of settlement, but less salvage and less amounts covered by reinsurance with other offices (wherever situated) ..
New Zealand Government taxes (show as dealt with in office accounts for year) ..
Local authority rates (include only proportion of rates applicable to premises or parts of premises used for fire-insurance business)
License fee .. .. ..
Fire Board levies .. .. .. ..
Rents (include only proportion of rents applicable to premises or parts of premises used for fire-insurance business) .. .. ..
Allowances and commissions on premiums to agents, subagents, or others .. .. ..
Salaries and wages, including commissions on profits or bonuses .. .. ..
Other expenses of management .. .. ..

Reserve:-

1. To meet unexpired risks as at end of year, being per cent. of net premium income .. .. ..
2. Additional to above (if any) ..
   Other expenditure (specify principal items):-

(b.) Revenue.
Reserve :-

1. To meet unexpired risks as at beginning of year, being per cent. of net premium income .. ..
2. Additional to above (if any) .. ..
   Net amount of fire premiums receivable during year (i.e., gross premiums, including reinsurance premiums receivable, but less reinsurance premiums payable and less return premiums) .. .. ..
   Interest and dividends on stock, mortgages, &c.
   Net rents--i.e., gross rents less expenditure (local authority rates, &c.), on properties from which derived .. ..
   Other revenue (specify principal items):-
   Balance for year .. ..
   Total .. ..

(c.) Not for Publication.
Amount of treaty commission receivable, £

Items of expenditure opposite which have been abated on account of above together with amounts by which abated in each case:-
Fire Board levies .. .. ..
Rents .. .. ..
Allowances and commissions, &c. ..
Salaries, wages, &c. ..
Other expenses of management ..

Total treaty commission receivable

Gross premium income--i.e., gross premiums received for New Zealand business (new and renewal) under-written during the year, including reinsurance premiums from other offices; no return premiums to be deducted .. .. .. £

Balance for year .. ..
Total .. .. £

Number of Policies.
£ s. d.
£ s. d.
£ s. d.