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                                                                                           NEAR FINAL 8/1/24
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                                                                                                                                                                                                                *226281*
    6  2024 M11, Insurance Premium Tax Return for Property and Casualty Companies                                                                                                                                                                                6
    7  Due March 1, 2025                                                                                                                            Check if:                                        Amended Return                                              7
    8                                  Name of Insurance Company                                                                                    FEIN                                          X                            Minnesota Tax ID(required)        8

    9                                  XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 0123456789                                                                                                                                      0123456789                        9
    10                                 Mailing Address                                                                  Check if New Address        NAIC Number                                                                State/Country of Incorporation    10
                                                                                                                                             X
    11                                 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 0123456789                                                                                                                                      0123456789                        11
    12                                 City                                                                          State         Zip Code         Contact Person                                                                                               12
    13                                 XXXXXXXXXXXXXXXXXXXXXXXX XX     XXXXX                                                                        XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 13
    14                                 Email Address                                                                 Daytime Phone                  Fax Number                                                                                                   14
             Print or Type
    15                                 XXXXXXXXXXXXXXXXXXXXXXXX 12345678900                                                                         012345678900                                                               012345678900                      15
    16                                 Type of Company:                        Stock     Mutual                        Other:                                                                                                                                    16
                                                                 X                    X              X
    17                                 Type of Premiums (Check All That Apply)          X Auto       X Fire/Property              X Bail Bonds  X Title                                           X Liability X Other            XXXXXXXXXXXXXX                  17
    18                                 This Return Includes:     X  M11B              X  IG259       X  IG258                 X  M11AR                                                                                                                           18
    19                                               Property, Casualty and Title Premiums                                                                                        A - State of Incorporation Basis       B - Minnesota Basis                     19
    20                                   1                  Minnesota fire and other premiums (see instructions)   . . .  . . . . . .  . . . . .  . . . . .  1                                    0123456789                      0123456789                     20
    21                                                                                                                                                                                                                                                           21
    22                                   2                  Accident and health premiums    .  . . . . .  . . . . . .  . . . . . .  . . . . . .  . . . . .  . . . . .  . . . .  2                 0123456789                      0123456789                     22
    23                                                                                                                                                                                                                                                           23
    24                                   3  Total Minnesota direct business (add lines 1 and 2)  . . .  . . . . . .  . . . . .  . . . . . .  . .  3                                               0123456789                      0123456789                     24
    25                                                                                                                                                                                                                                                           25
    26       Premiums                    4  Minnesota business assumed from unauthorized insurers (reinsurance)    . . . .  4                                                                                                                                    26
                                                                                                                                                                                                  0123456789
    27                                                                                                                                                                                                                                                           27
    28                                   5  Other additions (itemize on a separate schedule)    . . .  . . . . . .  . . . . .  . . . . . .  . . .  5                                              0123456789                      0123456789                     28
    29                                                                                                                                                                                                                                                           29
    30                                   6  Gross taxable business (add lines 3 through 5)  . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  6                                            0123456789                      0123456789                     30
    31                                                                                                                                                                                                                                                           31
    32                                   7  Direct ocean-marine premiums   . .  . . . . .  . . . . .  . . . . . .  . . . . . .  . . . . .  . . . . . .  . . .  7                                  0123456789                                                     32
    33                                                                                                                                                                                                                                                           33
    34                                   8  Dividends paid in cash (see instructions)  . . .  . . . . . .  . . . . .  . . . . . .  . . . . . .  . . . . .  8                                      0123456789                      0123456789                     34
    35                                                                                                                                                                                                                                                           35
    36       Deductions                  9  Other nontaxable business and dividends (attach a schedule)   . . .  . . . . . .  . . . .  9                                                          0123456789                      0123456789                     36
    37                                                                                                                                                                                                                                                           37
    38                                   10  Total deductions (add lines 7 through 9)   . . .  . . . . . .  . . . . .  . . . . . .  . . . . . .  . . .  .  10                                     0123456789                      0123456789                     38
    39                                                                                                                                                                                                                                                           39
    40                                   11                 Net taxable business (subtract line 10 from line 6)  . . .  . . . . . .  . . . . .  . . . . . . .  .            11                    0123456789                      0123456789                     40
    41                                                      Continue on line 15 of page 2.                                                                                                                                                                       41
    42                                   12    Tax due (or overpaid) . Enter amount from line 35   .  . . . . .  . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . .  . 12                            0123456789                     42
    43                                   13                 a Additional charge for underpaying estimated tax                                                                                                                                                    43
    44                                                        (determine from worksheet in the instructions, page 5)  . . .  . . . . . .  . . . . .                       13a                     0123456789                                                     44
    45                                               b  Penalty (see instructions)    . .  . . . . . .  . . . . . .  . . . . . .  . . . . .  . . . . . .  . . . . . .  .  13b                     0123456789                                                     45
    46                                               c  Interest (see instructions)   .  . . . . . .  . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . . .  . . .  . 13c                   0123456789                                                     46
    47                                                      Total (add lines 13a through 13c)   . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . .  . . . . . .  . . . . . .  . . .  . 13 0123456789                     47
    48                                                                                                                                                                                                                                                           48
    49                                   14                 TOTAL AMOUNT DUE (or overpaid  ) (add lines 12 and 13)   . . .  . . . . . .  . . . .  . 14                                            0123456789                                                     49
    50                                               If you owe additional tax:                                                                                                                                                                                  50
    51       Amount Due/Overpaid                            Payment method:           Electronic payment                Check (payable to Minnesota Revenue; write MN tax ID number on check; attach voucher)                                                    51
                                                                                 X                                   X
    52                                               Enter amount paid           0123456789                             Date paid 0123456789                                                                                                                     52
    53                                                      (If amount paid is different from amount due on line 14, attach an explanation.)                                                                                                                     53
    54                                                      If you overpaid:                                                                                                                                                                                     54
    55                                                      Amount on line 14 to be credited to next year’s estimated tax          . . .  . . . . . .  . . . . .  . . . . . . .  .                0123456789                                                     55
    56                                                      Amount on line 14 to be refunded   . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . .  . . . . . .  . . . . .  . . .  0123456789                                                     56
    57                                 I declare that this return is correct and complete to the best of my knowledge and belief.                                                                                                                                57
    58                                 I confess judgment to the state of Minnesota for the amount of tax shown due to the extent not timely paid.                                                                                                               58
    59                                 Authorized Signature                                     Title                                        Date                                                 Daytime Phone                                                  59
                                                                                                                                                                                                                                  X  I authorize the Minnesota 
    60                                                                                                                                                                                                                            Department of Revenue to       60
    61                                 SignatureXXXXXXXXXXXXXXXXXXXXof Preparer                 PrintXXXXXXXXXXXXXXXName Preparerof          DateXXXXXXXDaytimeXXXXXXXXXXXPhone                                                   discuss this tax return with   61
                          Sign Here                                                                                                                                                                                               the preparer .
    62                                 XXXXXXXXXXXXXXXXXXXX                                     XXXXXXXXXXXXXXX XXXXXXX XXXXXXXXXXX                                                                                                                              62
    63                                 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.                                                             63
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    4                                                                                                                                                                                                                                                                                                                       M11               4
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    6  2024 M11, Insurance Premium Tax Return for Property and Casualty Companies (Continued)                                                                                                                                                                                                                                                 6
    7                                                                                                                                                                                                                                                            A                                                          B                 7
    8                                                                                                                                                                                                                                            State of Incorporation Basis                                        Minnesota Basis          8
    9                                                 15                        Net taxable business (enter amounts from line 11)    .  . . . . .  . . . . . . .  . . . . .  . .  15                                                            0123456789                                                           0123456789               9
    10                                                                                                                                                                                                                                                                                                                                        10
    11                                                16                        Premium tax percentage rate*                                                  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16.  . 0123456789.  .  .  .  .  .  .  .  .                             %  0123456789%*             11
    12                                                                                                                                                                                                                                                                                                                                        12
    13                                                17                        Premium tax liability (multiply line 15 by percentage on line 16)    . . . . . .  . . .  17                                                                     0123456789                                                           0123456789               13
    14                                                                                                                                                                                                                                                                                                                                        14
    15                                                18  Fire insurance tax liability (from M11AR, line 12. Attach M11AR)  . . .  . . . . . .  18                                                                                              0123456789                                                                                    15
    16                                                                                                                                                                                                                                                                                                                                        16
    17                                                19  Other taxes (itemize on a separate schedule)   . .  . . . . .  . . . . . .  . . . . . .  . . . . . .  19                                                                              0123456789                                                                                    17
    18                                                                                                                                                                                                                                                                                                                                        18
    19                                                20  Total premium tax liability (add lines 17, 18 and 19)    .  . . . . .  . . . . . .  . . . . .  . .  20                                                                                0123456789                                                           0123456789               19
    20                                                                                                                                                                                                                                                                                                                                        20
    21                                                21                        Licenses and fees (from M11B, line 10. Attach M11B)   .  . . . . . .  . . . . . .  . . . . .  21                                                                0123456789                                                           0123456789               21
    22                                                                                                                                                                                                                                                                                                                                        22
    23                                                22  Total taxes, licenses and fees (add lines 20 and 21)   . . . .  . . . . . .  . . . . . .  . . . .  22                                                                                 0123456789                                                           0123456789               23
    24                                                                                                                                                                                                                                                                                                                                        24
    25                                                23                        Enter amount from line 22, Column A or B, whichever is greater   . . .  . . . . . .  . . . . . .  . . . . . .  . . . . .  . . . . .  23                                                                                              0123456789               25
    26                                                                                                                                                                                                                                                                                                                                        26
    27                                                24                        Total licenses and fees (from M11B, line 11. Attach M11B)                                                                                          . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  . . . .  24 0123456789               27
    28                                                25                        Subtract line 24 from line 23 (if zero or less, skip lines 26 through 30,                                                                                                                                                                                     28
    29                                                           and enter this amount on line 31)  . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . .  . . . . . .  . . . . . .  . . .                                                                                   25 0123456789               29
    30   Calculate Your Adjusted Liability                                                                                                                                                                                                                                                                                                    30
    31                                                26                        Minnesota Guaranty Fund Association offset (see instructions)   . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  26                                                                                             0123456789               31
    32                                                                                                                                                                                                                                                                                                                                        32
    33                                                27                        Minnesota Joint Underwriting Association (JUA) assessment (see instructions)   . . .  . . . . . .  . . . . . .  . . . .  27                                                                                                          0123456789               33
    34                                                                                                                                                                                                                                                                                                                                        34
    35                                                28                        Short Line Railroad Transfer Credit (attach credit certificate)  . . .  . . . . . .  . . . . .  . . . . . .  . . . . . .  . . . . .  . . . .  28                                                                                     0123456789               35
    36                                                                                                                                                                                                                                                                                                                                        36
    37                                                29                        Film Production Credit (attach credit certificate)  . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . . .  . .  29                                                                            0123456789               37
    38                                                30                        State Housing Tax Credit                                                                                                                                                                                                                                      38
    39                                                                          Enter the credit certificate number from State SHTCHousing:  -                                                                                     1234 -   5678900000                     . . .  . . 30.                            0123456789               39
    40                                                31                        Tax before refundable credits . If line 25 is zero or less, enter the amount from line 25 . If line 25 is                                                                                                                                                     40
    41                                                           positive, subtract any amounts on lines 26-30 from line 25.                                                                                                                                                                                                                  41
    42                                                           (If result is less than zero, enter zero)    . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . .  . . . . . .  . . . . .  . . . . . .  . . . . .  31                                                                                 0123456789               42
    43                                                32                        Credit for historic structure rehabilitation                                                                                                                                                                                                                  43
    44                                                                          (must attach credit certificate) and enter NPS project number:   . . . .  . . . .  .                                                                        0123456789                              32                               0123456789               44
    45                                                                                                                                                                                                                                                                                                                                        45
    46                                                33                        Tax liability (subtract line 32 from line 31)   . .  . . . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . .  . . . . . .  . . . . .  . . . .                                                                      33 0123456789               46
    47                                                34                        a  Prior year’s overpayment   . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . . .  . . . . .  . . . .  34a                                              0123456789                                                                                    47
    48                                                                                                                                                                                                                                                                                                                                        48
    49                                                           b  Estimated payment March 15                                                                 . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  .  .   34b 0123456789                                                                                    49
    50                                                                                                                                                                                                                                                                                                                                        50
    51                                                           c  Estimated payment June 15   . . . .  . . . . . .  . . . . . .  . . . . . .  . . . . .  . . . . . .  . .  34c                                                                0123456789                                                                                    51
    52                                                                                                                                                                                                                                                                                                                                        52
    53                                                           d  Estimated payment Sept. 15                                                                 . . .  . . . . . .  . . . . .  . . . . . .  . . . . . .  . . . . .  . . . .  34d 0123456789                                                                                    53
    54                                                                                                                                                                                                                                                                                                                                        54
    55                                                           e  Estimated payment Dec. 15    . . . .  . . . . . .  . . . . .  . . . . . .  . . . . . .  . . . . . .  . .  34e                                                               0123456789                                                                                    55
    56                                                           Add lines 34a through 34e   . . .  . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . . .  . . . . . .  . . . . . .  . . . . .  . . . . . .  . . . . . .  . . .  34                                                                            0123456789               56
    57   Tax Prepayments and Amount Due/Overpaid                                                                                                                                                                                                                                                                                              57
    58                                                35  Tax due (or overpaid) (subtract line 34 from line 33) Enter on line 12 on page 1.    . . .  . . . . .  . . . . . .  . . . .  35                                                                                                                            0123456789               58
    59 *  Line 16 — Tax Rates for Minnesota Basis (check one)                                                                                                                                                                                                                                                                                 59
    60                                           X   1% for mutual property and casualty insurance companies with total assets of $5 million or less at the end of the calendar year . Enter total assets at end of year: $                                                                                                                   60
    61                                           X   1.26% for mutual insurance companies that bothsell property and casualty insurance that had total assets greater than $5 atmillion the of theend calendar year, but thanless                                                                                                             61
    62                                               $1.6 billion on Dec. 31, 1989.                                                                                                                                                                                                                                                           62
    63                                           X   2% for insurance companies not listed above .                                                                                                                                                                                                                                            63
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