Lines Broker License Number Agency Name Print or Type July 1 - Dec. 31, 2026 (Due Feb. 15, 2027) Check if New Address Mailing Address Amended Return No Activity Return Date Licensed Minnesota Tax ID Number Required (see instructions) Social Security Number (last 4 digits) City State Zip Code Email Address Website Address Contact Person Daytime Phone Fax Number 1 Total premiums (from page 2, column G) . . . . . . . . . . . . . . . . . . . . . . . .

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