Form M11l - Insurance Premium Tax Return For Life And Health Companies - 2016
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5M11L
Page 1
2016 Insurance Premium Tax Return for Life and Health Companies
Due March 1, 2017
Check if:
Amended Return
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
Daytime Phone
Fax Number
Type of Premiums (Check All that Apply)
Type of Company
Health/Accident
Life
Other
Stock
Mutual
Part 1 — Life Premiums
A - State of Incorporation Basis
B - Minnesota Basis
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
1 1 Dividends to pay renewal premiums or reduce current premiums . . . . . . 1 1
1 2 Dividends applied to provide extended and paid-up additions
or shorten the premium paying period . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2
1 3 Dividends left on deposit to accumulate interest . . . . . . . . . . . . . . . . . . . 1 3
1 4 Unabsorbed portion of premiums credited to policyholders . . . . . . . . . . . 1 4
1 5 Other nontaxable business and dividends (attach a schedule) . . . . . . . . 1 5
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
1 8 Gross accident, health and other premiums . . . . . . . . . . . . . . . . . . . . . . . 1 8
19 Nontaxable premiums and dividends paid in cash . . . . . . . . . . . . . . . . . . 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 42) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
22
Total additional charge, penalty and interest (enter amount from line 43) . . . . . . . . . . . . . . . . . . . . 22
2 3
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 voucher)
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 Depart-
ment of Revenue to
Signature of Preparer
Print Name of Preparer
Date
Daytime Phone
discuss this tax return
with 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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