Form Dr-908 - Schedule Xvi - Surcharge On Commercial/residential Policies (2015)

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DR-908
R. 01/15
Page 12
Name _____________________________________ FEIN _________________________________ Taxable Year ______________
SCHEDULE XV
NOT USED
SCHEDULE XVI
SURCHARGE ON COMMERCIAL/RESIDENTIAL POLICIES
Policies Subject to Surcharge
Type of Policy
Rate
Surcharge Due
(sum of 4 quarters)
A.
Commercial
X $ 4.00
A.
B.
Residential
X $ 2.00
B.
*
Total Surcharge Due for the Calendar Year (Total A + B).
Enter here and include on Page 1, Line 10
with total from Schedule XVII.
*
The Total Surcharge Due should be greater than the sum of the first three quarters reported on Forms DR-907.
SCHEDULE XVII
PAYMENT DUE FROM FLORIDA LIFE AND HEALTH
INSURANCE GUARANTY ASSOCIATION (FLAHIGA) REFUND
1. Total payment due from FLAHIGA refunds received this year, if any, and previously claimed as credit.
Enter here and include on Page 1, Line 10 with total from Schedule XVI. See instructions.
Detach Here
Change of Address or Business Name
FEIN of Entity
Complete this form, sign it, and mail
Mail to:
CHANGE
IN
it to the Department if:
FLORIDA DEPARTMENT OF
Business
Location____________________________________________________
New
• The address below is not correct.
REVENUE
Location
• The business location changes.
5050 W TENNESSEE ST
Address
City______________________________ State_______ ZIP__________________
• The corporation name changes.
TALLAHASSEE FL 32399-0100
Business Telephone
(_______) _____________ County_____________________
In Care
of__________________________________________________________
Mailing
Address_____________________________________________________
New
Mailing
City_______________________________ State_______ ZIP_________________
Address
Owner’s Telephone
(_______) ______________ County_____________________
New
Business
DBA______________________________________________________________
Name
New
______________________________________________________
_________________________________________________________________________
Corporation
Signature of Officer (Required)
Date
Name
9100 9 20149999 0016045999 1 3999999999 0000 2

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