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.