M11H
2012 Insurance Premium Tax Return for HMOs
Due March 1, 2013
Check if:
Amended return
No activity
Name of provider
FEIN
Minnesota tax ID (required)
Mailing address
NAIC number
State/country of incorporation
Check if new address
City
State
Zip code
Contact person
Daytime phone
Email address
Website address
Fax number
Date licensed in Minnesota
1 Total gross written premiums (total from NAIC, Schedule T; attach a copy) . . . . . . . . . . . . . . . . . . . . . . . 1
2 a Federal employees health benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
b Nontaxable Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2b
c Other nontaxable premiums (attach separate itemized schedule) . . 2c
Total nontaxable premiums (add lines 2a, 2b and 2c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Other additions (attach separate itemized schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Total taxable premiums (add line 3 and line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1 %
6 Premium tax percentage rate (1%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7 Premium tax liability (multiply line 5 by line 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8 Premium tax prepayments
a Prior year‘s overpayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8a
b Estimated payment March 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8b
c Estimated payment June 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8c
d Estimated payment Sept . 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8d
e Estimated payment Dec . 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8e
Total payments (add lines 8a through 8e) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
9 Subtract line 8 from line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
10 a Additional charge for underpaying estimated tax
(determine from worksheet in the instructions) . . . . . . . . . . . . . . . . 10a
b Penalty (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10b
c Interest (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10c
Total (add lines 10a through 10c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11 TOTAL AMOUNT DUE (or overpaid) (add lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
If you owe additional tax:
Payment method:
Electronic payment
Check
(payable to Minnesota Revenue; write MN tax ID number on check; attach Form PV52)
Enter amount paid
Date paid
(If amount paid is different from amount due on line 11, attach an explanation.)
If you overpaid:
Amount on line 11 to be credited to next year‘s estimated tax . . . . . . . . . . .
Amount on line 11 to be refunded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I declare that this return is correct and complete to the best of my knowledge and belief.
Authorized signature
Title
Date
Daytime phone
I authorize the Minnesota
Department of Revenue to
discuss this tax return with
Signature of preparer
Print name of preparer
Date
Daytime phone
the preparer .
Mail to: Minnesota Revenue, Mail Station 1780, St . Paul, MN 55145-1780