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3 NEAR FINAL DRAFT 8/1/24 3
4 M11AR 4
5 5
6 6
7 2024 Fire Insurance Tax (Retaliatory Schedule) 7
8 Due March 1, 2025 8
9 Check if: Amended Return No Activity Return 9
X
10 Name of Insurance Company NAIC Number Minnesota Tax ID (required) State/CountryX Incorporationof 10
11 NAMEXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 1234567890 1234567890 XXXXXXXXXXXXX 11
12 12
13 Complete this form if your state of incorporation collects a fire insurance tax. 13
14 Note: Numbers in parentheses refer to line numbers 14
15 on NAIC Minnesota state page. Also include all finance A B C D E 15
16 and service charges. Total Direct Dividends Net Direct Premiums % of Fire State of 16
17 (A minus B) Incorporation Basis 17
18 (C times D) 18
19 1 Fire (1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.123456789 123456789 123456789 12345 123456789 19
20 20
21 2 Allied lines 21
22 a Crop (2 .1) . . . . . . . . . . . . . . . . . . . . . . . . .2a. 123456789 123456789 123456789 12345 123456789 22
23 b Other than crop (2 .1) . . . . . . . . . . . . . . . . 2b 123456789 123456789 123456789 12345 123456789 23
24 24
25 3 Multi-peril 25
26 a Farmowners (3) . . . . . . . . . . . . . . . . . . . . . 3a 123456789 123456789 123456789 12345 123456789 26
27 b Homeowners (4) . . . . . . . . . . . . . . . . . . . . 3b 123456789 123456789 123456789 12345 123456789 27
28 c Commercial nonliability (5 .1) . . . . . . . . . . 3c123456789 123456789 123456789 12345 123456789 28
29 d Commercial liability (5 .2) . . . . . . . . . . . . . 3d 123456789 123456789 123456789 12345 123456789 29
30 30
31 4 Inland marine (9) . . . . . . . . . . . . . . . . . . . . . . . 4 123456789 123456789 123456789 12345 123456789 31
32 32
33 5 Ocean marine (8) . . . . . . . . . . . . . . . . . . . . . . . 5 123456789 123456789 123456789 12345 123456789 33
34 34
35 6 Earthquake (12) . . . . . . . . . . . . . . . . . . . . . . . . 6 123456789 123456789 123456789 12345 123456789 35
36 7 Auto physical damage (21.1-21.2) 36
37 (total commercial and private) OR 37
38 itemize combined auto comprehensive 38
39 fire premiums (lines 7a–7f) . . . . . . . . . . . . . . 7.123456789 123456789 123456789 12345 123456789 39
40 a Comprehensive fire, theft and 40
41 miscellaneous (exclude collision) . . . . . . . 7a 123456789 123456789 123456789 12345 123456789 41
42 b Comprehensive fire, theft and 42
43 miscellaneous with deductible 43
44 (exclude collision) . . . . . . . . . . . . . . . . . . . 7b 123456789 123456789 12345 123456789 44
45 Fire c and theft combined . . . . . . . . . . . . . . 7c 123456789 123456789 123456789 12345 123456789 45
46 Fire, d theft and miscellaneous . . . . . . . . . . 7d 123456789 123456789 123456789 12345 123456789 46
47 e Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7e. 123456789 123456789 123456789 12345 123456789 47
48 f Collision and others . . . . . . . . . . . . . . . . . . 7f 123456789 123456789 123456789 12345 123456789 48
49 49
50 8Aircraft physical damage (22) . . . . . . . . . . . . 8.123456789 123456789 123456789 12345 123456789 50
51 51
52 9 Other fire (itemize on 52
53 a separate schedule) . . . . . . . . . . . . . . . . . . . . 9.123456789 123456789 123456789 12345 123456789 53
54 54
55 10 Taxable fire premiums (add lines 1 through 9, column E) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 123456789 55
56 56
57 11 Percentage rate for fire in the state/country of incorporation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 12345678 % 57
58 58
59 12 Fire insurance tax liability (multiply line 10 by the percentage on line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 123456789 59
60 Enter on Form M11, line 18, Column A. 60
61 61
62 Attach this form when you file your Form M11. Keep a copy for your records. 62
63 63
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65 65