1                                                                                                                                                                                                                                             1
  2 4  6 8      10 12  14        16  18  20         22  24  26            28  30       32  34  36 38  40   42  44  46 48  50 52  54  56 58  60  62  64  66 68  70                                                          72  74  76 78  80      82  84  86
    3                                                                                               FINAL DRAFT 10/2/23                                                                                                                           3
    4                                                                                                                                                                                                                      M11AR                  4
    5                                                                                                                                                                                                                                             5
    6                                                                                                                                                                                                                                             6
    7  2023 Fire Insurance Tax (Retaliatory Schedule)                                                                                                                                                                                             7
    8  Due March 1, 2024                                                                                                                                                                                                                          8
    9                                                                                                       Check if:                    Amended Return             No Activity Return                                                            9
                                                                                                                             X
    10 Name of Insurance Company                                                                            NAIC Number      Minnesota Tax ID (required)  State/Country of IncorporationX                                                         10

    11 NAMEXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 1234567890                                                                      1234567890                    XXXXXXXXXXXXX                                                                          11
    12                                                                                                                                                                                                                                            12
    13 Complete this form if your state of incorporation collects a fire insurance tax.                                                                                                                                                           13
    14 Note: Numbers in parentheses refer to line numbers                                                                                                                                                                                         14
    15 on NAIC Minnesota state page. Also include all finance                                     A                   B                  C                 D                                                                  E                   15
    16 and service charges.                                                                   Total Direct  Dividends        Net Direct Premiums         % of Fire                                                            State of            16
    17                                                                                                                                  (A minus B)                                                                           Incorporation Basis 17
    18                                                                                                                                                                                                                        (C times D)         18

    19   1  Fire (1)   . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . 1.123456789       123456789        123456789 12345                                                                                  123456789           19
    20                                                                                                                                                                                                                                            20
    21   2   Allied lines                                                                                                                                                                                                                         21
    22       a Crop (2 .1)   . . .  . . . . . .  . . . . .  . . . . . . .  . . . .2a.        123456789      123456789        123456789 12345                                                                                  123456789           22
    23       b Other than crop (2 .1)   . . . .  . . . . .  . . . . . .  . 2b                123456789      123456789        123456789 12345                                                                                  123456789           23
    24                                                                                                                                                                                                                                            24
    25    3  Multi-peril                                                                                                                                                                                                                          25
    26       a Farmowners (3)   . . .  . . . . . .  . . . . .  . . . . . . . 3a              123456789      123456789        123456789 12345                                                                                  123456789           26
    27       b Homeowners (4)   . .  . . . . . .  . . . . . .  . . . . .  . 3b               123456789      123456789        123456789 12345                                                                                  123456789           27
    28       c Commercial nonliability (5 .1)  . . .  . . . . . .  .   3c123456789                          123456789        123456789 12345                                                                                  123456789           28
    29       d Commercial liability (5 .2)   . . .  . . . . . . .  . . . 3d                  123456789      123456789        123456789 12345                                                                                  123456789           29
    30                                                                                                                                                                                                                                            30
    31   4  Inland marine (9)   .  . . . . .  . . . . . .  . . . . . .  . . . .  . 4 123456789              123456789        123456789              12345                                                                     123456789           31
    32                                                                                                                                                                                                                                            32
    33   5  Ocean marine (8)   .  . . . . . .  . . . . . .  . . . . .  . . . .  . 5 123456789               123456789        123456789              12345                                                                     123456789           33
    34                                                                                                                                                                                                                                            34
    35   6   Earthquake (12)    . . .  . . . . . .  . . . . .  . . . . .  . . . .  . 6 123456789            123456789        123456789              12345                                                                     123456789           35
    36    7  Auto physical damage (21.1-21.2)                                                                                                                                                                                                     36
    37       (total commercial and private) OR                                                                                                                                                                                                    37
    38       itemize combined auto comprehensive                                                                                                                                                                                                  38
    39       fire premiums (lines 7a–7f)   . . .  . . . . . .  . . . . . 7.123456789                        123456789        123456789 12345                                                                                  123456789           39
    40       a Comprehensive fire, theft and                                                                                                                                                                                                      40
    41         miscellaneous (exclude collision)  . . .  . . . .                      7a     123456789      123456789        123456789 12345                                                                                  123456789           41
    42       b Comprehensive fire, theft and                                                                                                                                                                                                      42
    43         miscellaneous with deductible                                                                                                                                                                                                      43
    44         (exclude collision)   . . . . .  . . . . . .  . . . . . .  . .  7b                           123456789        123456789              12345                                                                  123456789              44
    45       c Fire and theft combined                    . . .  . . . . . .  . . . . .   7c 123456789      123456789        123456789 12345                                                                               123456789              45
    46       d Fire, theft and miscellaneous                      . . .  . . . . . .  . 7d   123456789      123456789        123456789 12345                                                                               123456789              46
    47       e Fire   . . . .  . . . . . .  . . . . .  . . . . . .  . . . . . .  . . .7e.    123456789      123456789        123456789 12345                                                                               123456789              47
    48       f  Collision and others  . . .  . . . . . .  . . . . .  . . . .   7f            123456789      123456789        123456789 12345                                                                               123456789              48
    49                                                                                                                                                                                                                                            49
    50   8  Aircraft physical damage (22)    . . .  . . . . . .  . . . 8.123456789                          123456789        123456789 12345                                                                               123456789              50
    51                                                                                                                                                                                                                                            51
    52   9   Other fire (itemize on                                                                                                                                                                                                               52
    53       a separate schedule)               . . .  . . . . . .  . . . . .  . . . . . . 9.123456789      123456789        123456789 12345                                                                               123456789              53
    54                                                                                                                                                                                                                                            54
    55   10  Taxable fire premiums (add lines 1 through 9, column E)   . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . .  . . . . . .  . . . . . .  . 10 123456789                                       55
    56                                                                                                                                                                                                                                            56
    57   11  Percentage rate for fire in the state/country of incorporation                                 . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . .  . . . . . .  . . . 11 12345678 %          57
    58                                                                                                                                                                                                                                            58
    59   12  Fire insurance tax liability (multiply line 10 by the percentage on line 11)   . . . . .  . . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . .  . . . . . .  . . 12 123456789                                                 59
    60       Enter on Form M11, line 18, Column A.                                                                                                                                                                                                60
    61                                                                                                                                                                                                                                            61
    62    Attach this form when you file your Form M11. Keep a copy for your records.                                                                                                                                                             62
    63                                                                                                                                                                                                                                            63
  2 4  6 8      10 12  14        16  18  20         22  24  26           28  30        32  34  36 38  40   42  44  46 48  50 52  54  56 58  60  62  64  66 68  70                                                          72  74  76 78  80      82  84  86
    65                                                                                                                                                                                                                                            65

2023 Form M11AR Instructions

Use this form to determine the correct amount of premiums collected for all fire, sprinkler and lightning damage. Use these instructions as a 
guide. For further information, see M.S. 297I. The purpose of this form is to collect retaliatory tax on fire insurance premiums. 
Be sure to include this form when you file your Form M11.

Filing Requirements
All insurers that write or are authorized to write fire insurance in Minnesota must file Form M11AR if their home state collects a fire insur-
ance tax. This schedule is not required for companies domiciled in Minnesota, Arizona, Hawaii, Massachusetts, New York and Rhode 
Island. (M.S. 297I.05, subd. 11)

File Electronically
This schedule (Form M11AR) may be filed electronically using TriTech Software.

Instructions
Check Boxes
At the top of the form, check if the return is:
•  an Amended Return: Check only if you are amending a previously filed return for the same period. Include all original and corrected 
premiums on the amended return.
•  a No Activity Return: Check only if you did not sell any insurance that had fire, lightning or sprinkler leakage coverage for the year.
Line Instructions
Premiums include finance, service or other charges paid to the insurers.
Line 1
Enter all fire premiums written (line 1, Minnesota state page). 
Lines 2a and 2b
Enter all crop premiums written for allied lines on line 2a and other than crop premiums on line 2b (line 2.1, Minnesota state page).
Lines 3a and 3b
Enter all farmowners and homeowners multi-peril premiums written (lines 3 and 4, Minnesota state page).
Line 3c
Enter the nonliability portion of all commercial premiums written (line 5.1, Minnesota state page).
Line 3d
Enter the liability portion of all commercial premiums written (line 5.2, Minnesota state page).
Line 4 
Enter all inland marine premiums (line 9, Minnesota state page).
Line 5 
Enter all ocean marine premiums (line 8, Minnesota state page).
Line 6 
Enter all earthquake premiums (line 12, Minnesota state page).
Line 7 
Enter all total auto physical damage premiums (lines 21.1 – 21.2, Minnesota state page) OR:
7a.   all comprehensive fire, theft and miscellaneous premiums (excluding collision)
7b.   all comprehensive fire, theft and miscellaneous premiums with deductibles (excluding collision)
7c.   all fire and theft combined premiums
7d.   all fire, theft and miscellaneous premiums
7e.   all fire premiums
7f.   all collision and other premiums
The total auto physical damage premiums listed by breakdown (lines 7a through 7f) should equal total auto physical damage premiums on the 
state page of your annual statement.
Line 8
Enter all aircraft physical damage premiums (line 22, Minnesota state page).
Line 9
Include all other premiums collected for your home state’s fire insurance tax if not already included. Provide a breakdown schedule showing 
fire portion. For package policies, the fire insurance portion may be broken out to more accurately reflect the correct portion of fire premiums. 
Include a schedule detailing the breakdown.
                                                                                                       Continued                              1

2023 Form M11AR Instructions (Continued)

Information and Assistance
Website: www.revenue.state.mn.us
Email:  insurance.taxes@state.mn.us 
Phone:  651-556-3024 
This material is available in alternate formats.
For questions about licensing and regulations, contact the Minnesota Department of Commerce: 
Website: www.mn.gov/commerce
Email:  licensing.commerce@state.mn.us 
Phone:  651-539-1599 or 1-800-657-3978
Fax:    651-539-0107

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