Form M11 - Insurance Premium Tax Return For Property And Casualty Companies - 2012
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6M11
2012 Insurance Premium Tax Return for Property and Casualty Companies
Page 1
Due March 1, 2013
Check if:
Amended return
No activity
Name of insurance company
FEIN
Minnesota tax ID (required)
Mailing address
Check if new address
NAIC number
State/country of incorporation
City
State
Zip code
Contact person
Email address
Website address
Daytime phone
Fax number
Type of company
Date licensed in Minnesota
Stock
Mutual
Other:
Type of premiums (check all that apply)
Auto
Fire/Property
Health/Accident
Bail Bonds
Title
Liability
Other
This return includes:
M11B
IG259
IG258
M11AR
A - State of incorporation basis
B - Minnesota basis
Property, Casualty and Title Premiums
1 Minnesota fire and other premiums (see instructions) . . . . . . . . . . . . . . . . . . 1
2 Accident and health premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Total Minnesota direct business (add lines 1 and 2) . . . . . . . . . . . . . . . . . . . 3
4 Minnesota business assumed from unauthorized insurers (reinsurance) . . 4
5 Other additions (itemize on a separate schedule) . . . . . . . . . . . . . . . . . . . . . . 5
6 Gross taxable business (add lines 3 through 5) . . . . . . . . . . . . . . . . . . . . . . . 6
7 Direct ocean-marine premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8 Dividends paid in cash (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
9 Other nontaxable business and dividends (attach a schedule) . . . . . . . . . . . 9
10 Total deductions (add lines 7 through 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11 Net taxable business (subtract line 10 from line 6) . . . . . . . . . . . . . . . . . . . 11
Continue on line 15 of page 2.
12 Tax due (or overpaid) . Enter amount from line 32 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
13 a Additional charge for underpaying estimated tax
(determine from worksheet in the instructions, page 4) . . . . . . . . . . . 13a
b Penalty (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13b
c Interest (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13c
Total (add lines 13a through 13c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
14 TOTAL AMOUNT DUE (or overpaid) (add lines 12 and 13) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
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 amount due on line 14, attach an explanation .)
If you overpaid:
Amount on line 14 to be credited to next year’s estimated tax . . . . . . . . . . . . . . . . . . . . .
Amount on line 14 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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