NEAR FINAL DRAFT 8/1/24
                                                                                                                                                                                                                      M11AR

2024 Fire Insurance Tax (Retaliatory Schedule)
Due March 1, 2025
                                                                                                       Check if:     Amended Return                 No Activity Return 
Name of Insurance Company                                                                              NAIC Number  Minnesota Tax ID (required)  State/Country of Incorporation

Complete this form if your state of incorporation collects a fire insurance tax.
Note: Numbers in parentheses refer to line numbers  
on NAIC Minnesota state page. Also include all finance                                   A             B             C                         D                                                                         E
and service charges.                                                                     Total Direct  Dividends    Net Direct Premiums  % of Fire                                                                       State of
                                                                                                                    (A minus B)                                                                                          Incorporation Basis
                                                                                                                                                                                                                         (C times D)
  1  Fire (1)   . . .  . . . . . .  . . . . . .  . . . . . .  . . . . .  . . . . .  . 1                                                              

  2  Allied lines 
      a Crop (2 .1)   . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  2a                                                                    
      b Other than crop (2 .1)   . . . .  . . . . .  . . . . . .  .  2b                                                                              

   3  Multi-peril
      a Farmowners (3)   . . .  . . . . . .  . . . . .  . . . . . . .  3a                                                                            
      b Homeowners (4)   . . .  . . . . .  . . . . . .  . . . . .  .  3b                                                                             
      c Commercial nonliability (5 .1)  . . .  . . . . . .  .    3c                                                                                  
      d Commercial liability (5 .2)   . . .  . . . . . . .  . . .  3d                                                                                

  4  Inland marine (9)   . . . . . .  . . . . . .  . . . . . .  . . . .  . 4                                                                         

  5  Ocean marine (8)   . . . . .  . . . . . .  . . . . .  . . . . . .  . 5                                                                          

  6  Earthquake (12)    .  . . . . .  . . . . . .  . . . . .  . . . . . .  . 6                                                                       
   7  Auto physical damage (21.1-21.2)  
      (total commercial and private) OR  
      itemize combined auto comprehensive  
      fire premiums (lines 7a–7f)   . . .  . . . . . .  . . . . .  . 7                                                                               
      a Comprehensive fire, theft and  
        miscellaneous (exclude collision)  . . .  . . . .  7a                                                                                                                                                                                 
     b Comprehensive fire, theft and  
        miscellaneous with deductible  
        (exclude collision)   . . . . .  . . . . . .  . . . . . .  . .  7b                                                                           
      c Fire and theft combined     . . .  . . . . . .  . . . . .    7c                                                                              
      d Fire, theft and miscellaneous  . . .  . . . . . .  .  7d                                                                                     
      e Fire   . . . .  . . . . . .  . . . . . .  . . . . .  . . . . . . .  . . .  7e                                                                
      f  Collision and others  . . .  . . . . . .  . . . . .  . . . .    7f                                                                          

  8  Aircraft physical damage (22)    . . .  . . . . . .  . . .  . 8                                                                                 

  9  Other fire (itemize on  
      a separate schedule)  . . .  . . . . . .  . . . . .  . . . . . .  . 9                                                                          

  10 Taxable fire premiums (add lines 1 through 9, column E)   . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . . .  . 10 

  11  Percentage rate for fire in the state/country of incorporation                                   . . .  . . . . . .  . . . . .  . . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . .  . . . . . .  . . . 11                    %

  12  Fire insurance tax liability (multiply line 10 by the percentage on line 11)   .  . . . . . .  . . . . . .  . . . . .  . . . . . .  . . . . .  . . . . . .  . . . . . . 12 
     Enter on Form M11, line 18, Column A.

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