Enlarge image | NEAR FINAL DRAFT 8/1/24 *226281* 2024 M11L, Insurance Premium Tax Return for Life and Health Companies Due March 1, 2025 Check if: Amended Return Name of Insurance Company FEIN Minnesota Tax ID (required) Mailing Address Check if New Address NAIC Number State/Country of Incorporation City State Zip Code Contact Person Print or Type Email Address Daytime Phone Fax Number Type of Premiums (Check All that Apply) Type of Company Health/Accident Life Other Stock Mutual Part 1 — Life Premiums A - State of Incorporation Basis B - Minnesota Basis 1 Life premiums .. ...... ..... ...... ...... ...... ..... ..... ...... ..... 1 2 Annuity considerations ... ...... ..... ...... ...... ..... ...... ..... ... 2 3 Total Minnesota direct business (add lines 1 and 2) ... ...... ..... ...... .. 3 4 Minnesota business assumed from unauthorized insurers (reinsurance) ... .. 4 Premiums 5 Current dividends applied (see instructions) ... ...... ..... ....... ..... .. 5 6 Dividends previously left on deposit applied .. ....... ...... ..... ..... .. 6 7 Other additions (itemize on a separate schedule) .. ...... ...... ...... ... 7 8 Gross taxable business (add lines 3 through 7) ... ...... ..... ....... ..... 8 9 Deductible annuity considerations ... ...... ...... ...... ..... ...... .... 9 10 Dividends paid in cash (see instructions) ... ...... ..... ...... ...... .... 10 11 Dividends to pay renewal premiums or reduce current premiums ... ...... 11 12 Dividends applied to provide extended and paid-up additions or shorten the premium paying period ... ...... ..... ....... ..... ..... 12 13 Dividends left on deposit to accumulate interest ... ...... ..... ...... ... 13 Deductions 14 Unabsorbed portion of premiums credited to policyholders .. ...... ..... 14 15 Other nontaxable business and dividends (attach a schedule) .. ....... ... 15 16 Total deductions (add lines 9 through 15) ... ...... ..... ....... ..... ... 16 17 Net taxable business — Part 1 (subtract line 16 from line 8) ... ...... ..... 17 Part 2 — Accident and Health 18 Gross accident, health and other premiums ... ...... ..... ....... ..... . 18 Part 2 19 Nontaxable premiums and dividends paid in cash ... ...... ..... ....... . 19 20 Net taxable business — Part 2 (subtract line 19 from line 18) ... ...... .... 20 Continue on line 24 of page 2. 21 Tax due (or overpaid) (enter amount from line 45) .. ..... ...... ..... ....... ..... ...... ..... .. 21 22 Total additional charge, penalty and interest (enter amount from line 46) .. ..... ..... ....... ..... 22 23 TOTAL AMOUNT DUE (or overpaid) (add lines 21 and 22) ... ...... ..... ...... ...... ..... ..... 23 If you owe additional tax: Payment method: Electronic payment Check (payable to Minnesota Revenue; write MN tax ID number on check; attach voucher) Enter amount paid Date paid (If amount paid is different from line 23, attach an explanation.) If you overpaid: Amount Due/Overpaid Amount on line 23 to be credited to next year’s estimated tax .... ...... ... Amount on line 23 to be refunded . ..... ...... ..... ...... ..... ...... .. I declare that this return is correct and complete to the best of my knowledge and belief. I confess judgment to the state of Minnesota for the amount of tax shown due to the extent not timely paid. Authorized Signature Title Date Daytime Phone I authorize the Minnesota Department Sign Here Signature of Preparer Print Name of Preparer Date Daytime Phone of Revenue to discuss this tax return with the preparer. Mail to: Minnesota Department of Revenue, Mail Station 1780, 600 N. Robert St., St. Paul, MN 55146-1780. Do not send to the Minnesota Department of Commerce. |
Enlarge image | NEAR FINAL DRAFT 8/1/24 M11L Page 2 2024 Insurance Premium Tax Return for Life and Health Companies (continued) A B State of Incorporation Basis Minnesota Basis Part 1 — Life Premiums 24 Net taxable business (enter amount from line 17) ... ...... ..... ...... .. 24 25 Premium tax percentage rate .. ..... ...... ...... ...... ..... ...... .. 25 % 1.5% 26 Life premium tax liability (multiply line 24 by percentage on line 25) .. .... 26 Part 2 — Accident and Health 27 Net taxable business — Part 2 (enter amount from line 20) ... ...... ..... 27 28 Premium tax percentage rate .. ..... ...... ...... ...... ..... ...... .. 28 % 2% 29 Accident and health premium tax liability (multiply line 27 by the percentage on line 28) .. ..... ...... ..... ...... 29 30 Total premium tax liability (add lines 26 and 29) ... ...... ..... ....... .. 30 31 Other taxes (itemize on a separate schedule) .. ..... ...... ..... ...... . 31 32 Licenses and fees (from M11B, line 10. Attach form M11B) ... ...... ..... 32 33 Total taxes, licenses and fees (add lines 30 thru 32) ... ...... ...... ..... 33 34 Enter amount from line 33, Column A or B, whichever is greater . ..... ...... ..... ...... ...... .. 34 35 Total licenses and fees paid to Minnesota (from M11B, line 11. Attach form M11B) ... ...... ..... .. 35 36 Subtract line 35 from line 34 (if zero or less, skip lines 37 though 39 and enter this amount on line 40) ... ...... ..... ....... ..... ..... ...... 36 Calculate Your Adjusted Liability 37 Minnesota Guaranty Fund Association offset (see instructions) ... ...... ..... ...... ...... ..... .. 37 38 Short Line Railroad Transfer Credit (attach credit certificate) ... ..... ...... ...... ...... ..... .... 38 39 Film Production Credit (attach credit certificate) ..... ...... ...... ...... ...... ..... ..... ...... 39 40 State Housing Tax Credit ... ...... ..... ...... ...... ..... ...... ..... ...... ...... ..... ...... .40 Enter the credit certificate number from State Housing: SHTC - - 41 Tax before refundable credits. If line 36 is zero or less, enter the amount from line 36. If line 36 is positive, subtract any amounts on lines 37-40 from line 36. (If result is less than zero, enter zero) ... ...... ..... ....... ..... ...... ..... ...... ..... ...... 41 42 Historic structure rehabilitation credit (must attach credit certificate) enter NPS project number: ... ...... ... 42 43 Tax liability (subtract line 42 from line 41) ..... ...... ...... ...... ..... ...... ..... ...... ..... 43 44 a Prior year’s overpayment ...... ..... ..... .... 44a b Estimated payment March 15 ... ...... ..... ... 44b c Estimated payment June 15 .... ..... ...... ... 44c d Estimated payment Sept. 15 ... ...... ..... .... 44d e Estimated payment Dec. 15 .... ..... ...... ... 44e Tax Prepayments and Amount Due Add lines 44a through 44e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 45 Tax due (or overpaid) (subtract line 44 from line 43). Enter on line 21, page 1 .. ..... ..... ....... . 45 46 a Additional charge for underpaying estimated tax (determine from worksheet in the instructions)... 46a b Penalty (see instructions) ... ....... ..... ..... 46b c Interest (see instructions) . . . . . . . . . . . . . . . . . . . . 46c Penalty, Interest Total additional charge, penalty and interest (add lines 46a through 46c). Enter on line 22, page 1 ... ... 46 Additional Charge, |