1                                                                                                                                                                                                                                    1
                                                                                                        NEAR FINAL DRAFT 8/1/24
  2 4  6 8                    10  12  14   16  18  20                                       22  24  26  28  30     32  34  36 38  40      42  44  46     48  50  52  54  56    58  60  62 64  66         68  70 72  74  76       78  80  82  84  86
    3                                                                                                                                                                                                                                    3
    4                                                                                                                                                                                                                                    4
    5                                                                                                                                                                                                                                    5
                                                                                                                                                                                          *226281*
    6  2024 M11L, Insurance Premium Tax Return for Life and Health Companies                                                                                                                                                             6
    7  Due March 1, 2025                                                                                                                                                                                                                 7
    8                                                                                                                                                             Check if:          Amended Return                                      8
    9                            Name of Insurance Company                                                                                                       FEIN       X                        Minnesota Tax ID (required)         9

    10                           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 0123456789                                                                                                                  0123456789                          10
    11                           Mailing Address                                                                                Check if New Address             NAIC Number                         State/Country of Incorporation      11
                                                                                                                                                            X
    12                           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 0123456789                                                                                                                  XXXXXXXXXXXXXXX 12
    13                           City                                                                              State        Zip Code                         Contact Person                                                          13
    14                           XXXXXXXXXXXXXXXXXXXX XX     XXXXX                                                                                              XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 14
    15    Print or Type          Email Address                                                                                                                   Daytime Phone                        Fax Number                         15
    16                           XXXXXXXXXXXXXXXXXXXXXXXX 12345678900                                                                                           012345678900                         012345678900                        16
    17                           Type of Premiums (Check All that Apply)                                                        Type of Company                                                                                          17
    18                           X  Health/Accident                                         X  Life     X  Other                X   Stock        X  Mutual                                                                               18
    19                              Part 1 — Life Premiums                                                                                                              A - State of Incorporation Basis        B - Minnesota Basis      19
    20                             1   Life premiums   .. ...... ..... ...... ...... ...... ..... ..... ...... .....  1                                                0123456789                         0123456789                     20
    21                             2   Annuity considerations  ... ...... ..... ...... ...... ..... ...... ..... ...  2                                                0123456789                                                        21
    22                             3  Total Minnesota direct business (add lines 1 and 2) ... ...... ..... ...... ..  3                                                0123456789                                                        22
    23                             4  Minnesota business assumed from unauthorized insurers (reinsurance) ... ..  4                                                    0123456789                                                        23
    24    Premiums                 5  Current dividends applied (see instructions) ... ...... ..... ....... ..... ..  5                                                0123456789                         0123456789                     24
    25                             6  Dividends previously left on deposit applied   .. ....... ...... ..... ..... ..  6                                               0123456789                         0123456789                     25
    26                             7  Other additions (itemize on a separate schedule)   .. ...... ...... ...... ...  7                                                0123456789                         0123456789                     26
    27                             8  Gross taxable business (add lines 3 through 7)                                          ... ...... ..... ....... .....  8        0123456789                         0123456789                     27
    28                                                                                                                                                                                                                                   28
    29                             9  Deductible annuity considerations ... ...... ...... ...... ..... ...... ....  9                                                  0123456789                                                        29
    30                             10  Dividends paid in cash (see instructions)                                         ... ...... ..... ...... ...... ....  10       0123456789                         0123456789                     30
    31                             11  Dividends to pay renewal premiums or reduce current premiums ... ......  11                                                     0123456789                         0123456789                     31
    32                             12  Dividends applied to provide extended and paid-up additions                                                                                                                                       32
    33                                 or shorten the premium paying period  ... ...... ..... ....... ..... .....  12                                                  0123456789                         0123456789                     33
    34                             13  Dividends left on deposit to accumulate interest ... ...... ..... ...... ...  13                                                0123456789                         0123456789                     34
          Deductions
    35                             14  Unabsorbed portion of premiums credited to policyholders   .. ...... .....  14                                                  0123456789                         0123456789                     35
    36                             15  Other nontaxable business and dividends (attach a schedule)  .. ....... ...  15                                                                                                                   36
    37                             16  Total deductions (add lines 9 through 15)                                         ... ...... ..... ....... ..... ...  16        0123456789                         0123456789                     37
    38                             17  Net taxable business Part—                         1               (subtract line 16 from line 8) ... ...... .....        17    0123456789                         0123456789                     38
    39                                                                                                                                                                                                                                   39
    40                                 Part 2 — Accident and Health                                                                                                                                                                      40
    41                             18  Gross accident, health and other premiums                                          ... ...... ..... ....... ..... .  18         0123456789                         0123456789                     41
    42    Part 2  19                   Nontaxable andpremiums           dividends paid in cash                                  ... ...... ..... ....... .       19    0123456789                         0123456789                     42
    43                             20  Net taxable business Part—                         2               (subtract line 19 from line 18) ... ...... ....        20    0123456789                         0123456789                     43
    44                                 Continue on line 24 of page 2.                                                                                                                                                                    44
    45                                                                                                                                                                                                                                   45
    46                             21  Tax due (or overpaid) (enter amount from line 45)  .. ..... ...... ..... ....... ..... ...... ..... ..  21                                                         0123456789                     46
    47                            22  Total additional charge, penalty and interest (enter amount from line 46)  .. ..... ..... ....... .....  22                                                         0123456789                     47
    48                             23  TOTAL AMOUNT DUE (or                                             overpaid)   (add lines 21 and 22)   ... ...... ..... ...... ...... ..... ..... 23                 0123456789                     48
    49                              If you owe additional tax:                                                                                                                                                                           49
    50                                 Payment method:                                         X    Electronic payment        X     Check (payable to Minnesota Revenue; write MN tax ID number on check; attach voucher)                50
    51                              Enter amount paid                                          0123456789   Date paid                     0123456789  (If amount paid is different from line 23, attach an explanation.)                 51
    52                                 If you overpaid:                                                                                                                                                                                  52
    53    Amount Due/Overpaid          Amount on line 23 to be credited to next year’s estimated tax  .... ...... ...                                                                                                                    53
                                                                                                                                                                       0123456789
    54                                 Amount on line 23 to be refunded   . ..... ...... ..... ...... ..... ...... ..                                                  0123456789                                                        54
    55                                                                                                                                                                                                                                   55
    56                            I declare that this return is correct and complete to the best of my knowledge and belief.                                                                                                             56
    57                            I confess judgment to the state of Minnesota for the amount of tax shown due to the extent not timely paid.                                                                                            57
                                                                                                                                                                                                             
    58                            Authorized Signature                                                             Title                                    Date            Daytime Phone                 X     I authorize the          58
    59              Sign Here    XXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXX 0123456789                                                                                                                        Minnesota Department     59
    60                            Signature of Preparer                                                            Print Name of Preparer                   Date            Daytime Phone                       of Revenue to discuss    60
                                                                                                                                                                                                                this tax return with the 
    61                                                                                                                                                                                                          preparer.                61
                                 XXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXX 0123456789
    62                                                                                                                                                                                                                                   62
    63                            Mail to: Minnesota Department of Revenue, Mail Station 1780, 600 N. Robert St., St. Paul, MN 55146-1780. Do not send to the Minnesota Department of Commerce.                                          63
  2 4  6 8                    10  12  14   16  18  20                                       22  24  26  28  30     32  34  36 38  40      42  44  46     48  50  52  54  56  58  60  62   64  66         68  70 72  74  76       78  80  82  84  86
    65                                                                                                                                                                                                                                   65

    1                                                                                                                                                                                                                                                                                                           1
                                                                                                                                                                                        NEAR FINAL DRAFT 8/1/24
  2 4  6                               8                                                                   10  12  14             16  18  20                       22  24  26           28  30 32  34  36 38  40 42  44  46 48  50      52  54  56          58  60  62 64  66      68  70 72  74  76     78  80 82  84  86
    3                                                                                                                                                                                                                                                                                                           3
    4                                                                                                                                                                                                                                                                                     M11L                  4
    5                                                                                                                                                                                                                                                                                     Page 2                5
    6                                                                                                                                                                                                                                                                                                           6
    7  2024 Insurance Premium Tax Return for Life and Health Companies (continued)                                                                                                                                                                                                                              7
    8                                                                                                                                                                                                                                                                                                           8
                                                                                                                                                                                                                                                            A                             B
    9                                                                                                                                                                                                                                                 State of Incorporation Basis        Minnesota Basis       9
    10                                                                                                              Part 1 — Life Premiums                                                                                                                                                                      10
    11                                                                                                         24         Net taxable business (enter amount from line 17) ... ...... ..... ...... ..  24                                            0123456789                     0123456789                  11
    12                                                                                                         25         Premium tax percentage rate  .. ..... ...... ......                  ...... ..... ...... ..                          25    0123456789 %                                    1.5%       12
    13                                                                                                         26         Life premium tax liability (multiply line 24 by percentage on line 25)  .. ....  26                                        0123456789                     0123456789                  13
    14                                                                                                                                                                                                                                                                                                          14
    15                                                                                                            Part 2 — Accident and Health                                                                                                                                                                  15
    16                                                                                                         27  Net taxable business — Part 2 (enter amount from line 20)                                         ... ...... .....  27            0123456789                     0123456789                  16
    17                                                                                                         28  Premium tax percentage rate  .. ..... ...... ...... ...... ..... ...... ..  28                                                    0123456789 %                                         2%    17
    18                                                                                                         29         Accident and health premium tax liability                                                                                                                                             18
    19                                                                                                                    (multiply line 27 by the percentage on line 28)  .. ..... ...... ..... ......  29                                          0123456789                     0123456789                  19
    20                                                                                                         30         Total premium tax liability (add lines 26 and 29)                                    ... ...... ..... ....... ..  30       0123456789                     0123456789                  20
    21                                                                                                         31  Other taxes (itemize on a separate schedule)   .. ..... ...... ..... ...... .  31                                                 0123456789                                                 21
    22                                                                                                         32         Licenses and fees (from M11B, line 10. Attach form M11B)                                   ... ...... .....  32            0123456789                     0123456789                  22
    23                                                                                                         33  Total taxes, licenses and fees (add lines 30 thru 32)  ... ...... ...... .....  33                                                0123456789                     0123456789                  23
    24                                                                                                         34         Enter amount from line 33, Column A or B, whichever is greater  . ..... ...... ..... ...... ...... ..  34                                                 0123456789                  24
    25                                                                                                         35         Total licenses and fees paid to Minnesota (from M11B, line 11. Attach form M11B) ... ...... ..... ..  35                                                  0123456789                  25
    26                                                                                                         36         Subtract line 35 from line 34 (if zero or less,                                                                                                                                       26
    27                                                                                                             skip lines 37 though 39 and enter this amount on line 40) ...                                   ...... ..... ....... ..... ..... ......                  36      0123456789                  27
    28                                                    Calculate Your Adjusted Liability                    37         Minnesota Guaranty Fund Association offset (see instructions) ... ...... ..... ...... ...... ..... ..  37                                                 0123456789                  28
    29                                                                                                         38         Short Line Railroad Transfer Credit (attach credit certificate) ... ..... ...... ...... ...... ..... ....  38                                             0123456789                  29
    30                                                                                                         39         Film Production Credit (attach credit certificate) ..... ...... ...... ...... ...... ..... ..... ......  39                                               0123456789                  30
    31                                                                                                         40         State Housing Tax Credit ... ...... ..... ...... ...... ..... ...... ..... ...... ...... ..... ...... .40                                                 0123456789                  31
    32                                                                                                                    Enter the credit certificate number from State Housing: SHTC -                                  1234 -        123456789                                                               32
    33                                                                                                         41         Tax before refundable credits. If line 36 is zero or less, enter the amount from line 36. If line 36 is                                                                               33
    34                                                                                                             positive, subtract any amounts on lines 37-40 from line 36.                                                                                                                                  34
    35                                                                                                                    (If result is less than zero, enter zero)                            ... ...... ..... ....... ..... ...... ..... ...... ..... ......  41                  0123456789                  35
    36                                                                                                         42  Historic structure rehabilitation credit                                                                                                                                                     36
    37                                                                                                             (must attach credit certificate) enter NPS project number:                                         ... ...... ...    0123456789                        42        0123456789                  37
    38                                                                                                         43  Tax liability (subtract line 42 from line 41)  ..... ...... ...... ...... ..... ...... ..... ...... .....  43                                                    0123456789                  38
    39                                                                                                                                                                                                                                                                                                          39
    40                                                                                                         44         a  Prior year’s overpayment  ...... ..... ..... ....  44a                                   0123456789                                                                                40
    41                                                                                                             b  Estimated payment March 15 ... ...... ..... ...  44b                                            0123456789                                                                                41
    42                                                                                                             c  Estimated payment June 15  .... ..... ...... ...                                            44c 0123456789                                                                                42
    43                                                                                                             d  Estimated payment Sept. 15  ... ...... ..... ....  44d                                          0123456789                                                                                43
    44                                                                                                             e  Estimated payment Dec. 15   .... ..... ...... ...  44e                                          0123456789                                                                                44
    45                 Tax Prepayments                                                      and Amount Due         Add lines 44a through 44e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  44      0123456789                  45
    46                                                                                                         45  Tax due (or overpaid) (subtract line 44 from line 43). Enter on line 21, page 1  .. ..... ..... ....... .  45                                                    0123456789                  46
    47                                                                                                                                                                                                                                                                                                          47
    48                                                                                                         46         a  Additional charge for underpaying estimated tax                                                                                                                                    48
    49                                                                                                                                (determine from worksheet in the instructions)...  46a                          0123456789                                                                                49
    50                                                                                                             b  Penalty (see instructions)  ... ....... ..... .....  46b                                        0123456789                                                                                50
    51                                                                                                             c                  Interest (see instructions)  . . . . . . . . . . . . . . . . . . . .        46c 0123456789                                                                                51
    52                                                                                      Penalty, Interest      Total additional charge, penalty and interest (add lines 46a through 46c). Enter on line 22, page 1 ... ... 46                                                   0123456789                  52
    53                                 Additional Charge,                                                                                                                                                                                                                                                       53
    54                                                                                                                                                                                                                                                                                                          54
    55                                                                                                                                                                                                                                                                                                          55
    56                                                                                                                                                                                                                                                                                                          56
    57                                                                                                                                                                                                                                                                                                          57
    58                                                                                                                                                                                                                                                                                                          58
    59                                                                                                                                                                                                                                                                                                          59
    60                                                                                                                                                                                                                                                                                                          60
    61                                                                                                                                                                                                                                                                                                          61
    62                                                                                                                                                                                                                                                                                                          62
    63                                                                                                                                                                                                                                                                                                          63
  2 4  6                               8                                                                   10 12  14              16  18  20                       22  24  26           28  30 32  34  36 38  40 42  44  46 48  50      52  54  56          58  60  62 64  66      68  70 72  74  76     78  80 82  84  86
    65                                                                                                                                                                                                                                                                                                          65