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2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 FINAL DRAFT42 44 46 10/2/2348 50 52 54 56 58 60 62 64 66 68 70 72 74 76 78 80 82 84 86
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4 M11B 4
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6 6
7 7
8 2023 Insurance Fees Schedule 8
9 Due March 1, 2024 9
10 10
11 Check if: Amended Return 11
12 Name of Insurance Company NAIC Number XMinnesota Tax ID (required) State/Country of Incorporation 12
13 NAMEXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 1234567890 1234567890 XXXXXXXXXXXXX 13
14 14
15 THIS IS NOT A BILL. DO NOT SEND PAYMENT FOR FEES. 15
16 16
17 Instructions 17
18 Enter the fees paid to the insurance licensing agency in your state/country of incorporation (Column A) as they would apply to a Minnesota 18
19 company licensed and doing business in that state or country, and the fees paid to the Minnesota Department of Commerce (Column B) for each 19
20 item. This form is not required for companies domiciled in Minnesota, Arizona, Hawaii, Massachusetts, New York and Rhode Island. (M.S. 297I.05, 20
21 subd. 11) 21
22 Line 9. Do not include examination fees, fraud fees or assessments, OET surcharge, insurance guaranty association assessments, workers’ 22
23 compensation association assessments, second-injury fund assessments, or any other special obligations or assessments on line 9. Only include fees 23
24 that are paid to the general fund. 24
25 A B 25
26 Fee Paid to Fee Paid to Minnesota 26
27 State/Country of Incorporation Department of Commerce 27
28 28
29 1 Fees for filing articles of incorporation and/or amendments . . . . . . . . . . . . 1 123456789000 123456789000 29
30 30
31 2 Fees for filing bylaws and/or amendments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 123456789000 123456789000 31
32 32
33 3 Fee for filing annual statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 123456789000 123456789000 33
34 34
35 4 Fee for Certificate of Authority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 123456789000 123456789000 35
36 5 Fee for valuing life insurance policies (non-Minnesota 36
37 life insurance companies only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 123456789000 123456789000 37
38 38
39 6 Fees for filing forms and rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 123456789000 123456789000 39
40 7 Agents’ licensing fees charged to insurer 40
41 (for those agents licensed in Minnesota only) . . . . . . . . . . . . . . . . . . . . . . . . . 7 123456789000 123456789000 41
42 42
43 8 Admission, application and license fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 123456789000 123456789000 43
44 Insurer’s Fees and Licenses 44
45 9 Other fees (see instructions above) 45
46 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX . . . . . . 9a 123456789000 123456789000 46
47 47
48 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX . . . . . . . 9b 123456789000 123456789000 48
49 49
50 10 Total fees and licenses (add lines 1 through 9) . . . . . . . . . . . . . . . . . . . . . . . 10 123456789000 123456789000 50
51 Enter on Form M11, line 21, or on Form M11L, line 32. 51
52 52
53 11 Total fees and licenses paid to the Minnesota Commerce Department (amount from line 10B) . . . . . . . 11 123456789000 53
54 Enter this amount on Form M11, line 24, or on Form M11L, line 35. 54
55 55
56 Attach this form when you file your Form M11 or Form M11L. Keep a copy for your records. 56
57 57
58 NOTE: FEES ARE NOT PAID TO THE DEPARTMENT OF REVENUE. 58
59 Fees are not a refundable credit and cannot be used as a credit on future returns. 59
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