Form M11l - Insurance Premium Tax Return For Life And Health Companies - Minnesota Department Of Revenue - 2013

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M11L
Page 1
2013 Insurance Premium Tax Return for Life and Health Companies
Due March 1, 2014
Check if:
Amended return
No activity
Name of insurance company
FEIN
Minnesota tax ID (required)
Mailing address
NAIC number
State/country of incorporation
Check if new address
City
State
Zip code
Contact person
Email address
Website address
Daytime phone
Fax number
Type of premiums (check all that apply)
Type of company
Date licensed in Minnesota
Health/Accident
Life
Other
Stock
Mutual
A - State of Incorporation Basis
B - Minnesota Basis
Part 1 — Life Premiums
1 Life premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Annuity considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Total Minnesota direct business (add lines 1 and 2) . . . . . . . . . . . . . . . . . . . 3
4 Minnesota business assumed from unauthorized insurers (reinsurance). . . 4
5 Current dividends applied (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Dividends previously left on deposit applied . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7 Other additions (itemize on a separate schedule) . . . . . . . . . . . . . . . . . . . . . . 7
8 Gross taxable business (add lines 3 through 7) . . . . . . . . . . . . . . . . . . . . . . . 8
9 Deductible annuity considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
10 Dividends paid in cash (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11 Dividends to pay renewal premiums or reduce current premiums . . . . . . . 11
12 Dividends applied to provide extended and paid-up additions
or shorten the premium paying period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Dividends left on deposit to accumulate interest . . . . . . . . . . . . . . . . . . . . . 13
14 Unabsorbed portion of premiums credited to policyholders . . . . . . . . . . . . . 14
15 Other nontaxable business and dividends (attach a schedule) . . . . . . . . . . 15
16 Total deductions (add lines 9 through 15) . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
17 Net taxable business — Part 1 (subtract line 16 from line 8) . . . . . . . . . . . . 17
Part 2 — Accident and Health
18 Accident, health and other premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
19 Dividends paid in cash (accident and health) . . . . . . . . . . . . . . . . . . . . . . . . 19
20 Net taxable business — Part 2 (subtract line 19 from line 18) . . . . . . . . . . . 20
Continue on line 24 of page 2.
21 Tax due (or overpaid) (enter amount from line 43) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Total additional charge, penalty and interest (enter amount from line 44) . . . . . . . . . . . . . . . . . . . . . 22
23 TOTAL AMOUNT DUE (or overpaid) (add lines 21 and 22) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
If you owe additional tax:
Payment method:
Electronic payment
Check
(payable to Minnesota Revenue; write MN tax ID number on check; attach Form PV42)
Enter amount paid
Date paid
(If amount paid is different from line 23, attach an explanation.)
If you overpaid:
Amount on line 23 to be credited to next year’s estimated tax . . . . . . . . . . . .
Amount on line 23 to be refunded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I declare that this return is correct and complete to the best of my knowledge and belief.
I confess judgment to the state of Minnesota for the amount of tax shown due to the extent not timely paid.
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. Do not send to the Minnesota Department of Commerce.

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