Fillable Form M11ar - Fire Insurance Tax - 2012 printable pdf download

Form M11ar - Fire Insurance Tax - 2012

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M11AR

Attachment #4

2012 Fire Insurance Tax

(Retaliatory Schedule)

Due March 1, 2013

Check if:

Amended return

No activity

Name of insurance company

NAIC number

Minnesota tax ID (required)

State/country of incorporation

Complete this form if your state of incorporation collects a fire insurance tax.

Note: Numbers in parentheses refer to line numbers

on NAIC Minnesota state page. Also include all finance

Total direct

Dividends

Net Direct Premiums

% of Fire

State of

and service charges.

(A minus B)

Incorporation Basis

(C times D)

1 Fire (1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Allied lines

a Crop (2 . 1 ) . . . . . . . . . . . . . . . . . . . . . . . . 2a

b Other than crop (2 . 1 ) . . . . . . . . . . . . . . . 2b

3 Multi-peril

a Farmowners (3) . . . . . . . . . . . . . . . . . . . 3a

b Homeowners (4) . . . . . . . . . . . . . . . . . . . 3b

c Commercial nonliability (5 . 1 ) . . . . . . . . 3c

d Commercial liability (5 .2) . . . . . . . . . . . . 3d

4 Inland marine (9) . . . . . . . . . . . . . . . . . . . . . 4

5 Ocean marine (8) . . . . . . . . . . . . . . . . . . . . . 5

6 Earthquake (12) . . . . . . . . . . . . . . . . . . . . . . 6

7 Auto physical damage (21 . 1 -21 .2)

(total commercial and private) OR

itemize combined auto comprehensive

fire premiums (lines 7a–7f) . . . . . . . . . . . . . 7

a Comprehensive fire, theft and

miscellaneous (exclude collision) . . . . . 7a

b Comprehensive fire, theft and

miscellaneous with deductible

(exclude collision) . . . . . . . . . . . . . . . . . . 7b

c Fire and theft combined . . . . . . . . . . . . 7c

d Fire, theft and miscellaneous . . . . . . . . 7d

e Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7e

f Collision and others . . . . . . . . . . . . . . . . 7f

8 Aircraft physical damage (22) . . . . . . . . . . . 8

9 Other fire (itemize on

a separate schedule) . . . . . . . . . . . . . . . . . . 9

10 Taxable fire premiums (add lines 1 through 9, column E) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

11 Percentage rate for fire in the state/country of incorporation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

12 Fire insurance tax liability (multiply line 10 by the percentage on line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Enter on Form M11, line 18, Column A.

Include this report when your file your Form M11. Keep a copy for your records.