Fillable Form M11b - Insurance Fees Schedule - 2012 printable pdf download

Form M11b - Insurance Fees Schedule - 2012

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M11B

Attachment #1

2012 Insurance Fees 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

THIS IS NOT A BILL. DO NOT SEND PAYMENT FOR FEES.

Instructions

Enter the fees paid to the insurance licensing agency in your state/country of incorporation (Column A) as they would apply to a Minnesota

company licensed and doing business in that state or country, and the fees paid to the Minnesota Department of Commerce (Column B) for

each item. This form is not required for companies domiciled in Minnesota, Hawaii, Massachusetts, New York and Rhode Island. (M.S. 297I.05,

subd. 11)

Line 9. Do not include examination fees, fraud assessments or fees, OET fees, insurance guaranty association assessments, workers’ compensation

association assessments, second-injury fund assessments, or any other special obligations or assessments on line 9. Only include fees that

are paid to the general fund.

Fee Paid to

Fee Paid to Minnesota

State/Country of Incorporation

Department of Commerce

1 Fees for filing articles of incorporation and/or amendments . . . . . . . . . . . 1

2 Fees for filing bylaws and/or amendments

(Minnesota’s fee: $75 per filing) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 Fee for filing annual statement

(Minnesota’s fee: $225 per filing) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

4 Fee for Certificate of Authority

(Minnesota’s fee: $575 per filing) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

5 Fee for valuing life insurance policies (non-Minnesota

life insurance companies only). (Minnesota’s fee: $50 annually) . . . . . . . 5

6 Fees for filing forms and rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

7 Agents’ licensing fees charged to insurer

(for those agents licensed in Minnesota only) . . . . . . . . . . . . . . . . . . . . . . . 7

8 Admission, application and license fees . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

9 Other fees (see instructions above)

. . . . . 9a

. . . . . . 9b

10 Total fees and licenses (add lines 1 through 9) . . . . . . . . . . . . . . . . . . . . 10

Enter on Form M11, line 21, or on M11L, line 33.

11 Total fees and licenses paid to the Minnesota Commerce Department (amount from line 10B) . . 11

Enter this amount on Form M11, line 24, or on M11L, line 36.

Include this form when you file your Form M11 or M11L.

NOTE: FEES ARE NOT PAID TO THE DEPARTMENT OF REVENUE.

Fees are not a refundable credit and cannot be used as a credit on future returns.

Form M11b - Insurance Fees Schedule - 2012

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