Form M11ar - Fire Insurance Tax - 2014
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1
2M11AR
Attachment #4
2014 Fire Insurance Tax
(Retaliatory Schedule)
Due March 1, 2015
Check if:
Amended Return
No Activity
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
A
B
C
D
E
on NAIC Minnesota state page. Also include all finance
Total Direct
Dividends
Net Direct Premiums
% of Fire
State of
and service charges.
(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.
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