FINAL DRAFT 10/2/23
                                                                                                                                                                                                                  M11B

2023 Insurance Fees Schedule
Due March 1, 2024
                                                                                                                      Check if:                                                    Amended Return  
Name of Insurance Company                                                                                             NAIC Number                                                 Minnesota Tax ID (required)  State/Country of Incorporation

THIS IS NOT A BILL. DO NOT SEND PAYMENT FOR FEES.                                                                   

Instructions
Enter the fees paid to the insurance licensing agency in your state/country of incorporation (Column A) as they would apply to a Minnesota 
company licensed and doing business in that state or country, and the fees paid to the Minnesota Department of Commerce (Column B) for each 
item. This form is not required for companies domiciled in Minnesota, Arizona, Hawaii, Massachusetts, New York and Rhode Island. (M.S. 297I.05, 
subd. 11)
Line 9. Do not include examination fees, fraud fees or assessments, OET surcharge, insurance guaranty association assessments, workers’ 
compensation association assessments, second-injury fund assessments, or any other special obligations or assessments on line 9. Only include fees 
that are paid to the general fund.
                                                                                                                                                                                   A                              B
                                                                                                                                                                                  Fee Paid to                     Fee Paid to Minnesota
                                                                                                                                                                                   State/Country of Incorporation Department of Commerce

                                                       1  Fees for filing articles of incorporation and/or amendments   . . . . . .  . . . . . .  1                                                 

                                                        2  Fees for filing bylaws and/or amendments  . . .  . . . . .  . . . . . .  . . . . .  . . . . .  . . .  . 2                                

                                                        3  Fee for filing annual statement  . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  . . . . .  . 3                    

                                                        4  Fee for Certificate of Authority  . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  . . . . .  4                     
                                                        5  Fee for valuing life insurance policies (non-Minnesota  
                                                          life insurance companies only)   . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  . . . . .  5                       

                                                       6  Fees for filing forms and rates   . . . .  . . . . .  . . . . . .  . . . . .  . . . . . .  . . . . . .  . . . . .  6                      
                                                        7  Agents’ licensing fees charged to insurer  
                                                          (for those agents licensed in Minnesota only)  . . .  . . . . . .  . . . . .  . . . . . . .  . . . .  7                                   

                                                        8  Admission, application and license fees   . . . . . .  . . . . . .  . . . . .  . . . . . .  . . . . . .  8                               
                           Insurer’s Fees and Licenses
                                                        9  Other fees (see instructions above)
                                                                                                                        . . .  . . .  9a                                                            

                                                                                                                        . . .  . . .  . 9b                                                          

                                                        10 Total fees and licenses (add lines 1 through 9)   . . .  . . . . . .  . . . . .  . . . . . . .  . .  10                                  
                                                           Enter on Form M11, line 21, or on Form M11L, line 32.

                                                        11  Total fees and licenses paid to the Minnesota Commerce Department (amount from line 10B)    . . . .  . .  . 11 
                                                           Enter this amount on Form M11, line 24, or on Form M11L, line 35. 

                                                          Attach this form when you file your Form M11 or Form M11L. Keep a copy for your records.

                                                       NOTE: FEES ARE NOT PAID TO THE DEPARTMENT OF REVENUE. 
                                                       Fees are not a refundable credit and cannot be used as a credit on future returns.