Form 800es - Virginia Insurance Premiums License Tax Estimated Payment Voucher - 2017 Page 2
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1
2
3
4Estimated Tax Worksheet
(This is your record - retain for your files)
Estimated Direct Gross
Rate
Initial Premiums Li-
Premiums
cense Tax
LIFE & ACCIDENT and HEALTH INSURANCE COMPANIES:
Life
$
.00
X 2.25% =
$
.00
Disability & Double Indemnity
$
.00
X 2.25% =
$
.00
Accident & Sickness
$
.00
X 2.25% =
$
.00
Industrial Sick Benefit
$
.00
X 1.00% =
$
.00
TOTAL
$
.00
$
.00
FIRE, CASUALTY and TITLE INSURANCE COMPANIES:
All lines of insurance (except Workers’ Compensation) less divi-
dends to policyholders of Mutual Insurance Companies.
$
.00
X 2.25% =
$
.00
1. Complete the Estimated Tax Worksheet below to compute your estimated tax for 2017.
A. Estimated tax payable this year from above worksheet. Enter this amount on Line 2 of the voucher ..................... 1A. $
.00
B. If first filing is on or before:
April 15, 2017 enter 1/4 of Line 1A here.
June 15, 2017 enter 1/3 of Line 1A here.
Sept. 15, 2017 enter 1/2 of Line 1A here.
Dec. 15, 2017 enter amount on Line 1A here. ......................................................................................................... 1B. $
.00
2. Enter the estimated payment amount from Line 1B (above), on Line 3 of the first voucher.
3. The amount of SUBSEQUENT installment payments due (to be shown on Line 2 of the appropriate voucher) will be the amount shown
on Line 1B (above).
HOW TO COMPLETE THE FORM 800ES VOUCHERS
1. Enter your Virginia tax account number.
2. Enter the federal employer identification number, NAIC/License number, name, address, city, state and ZIP code on each voucher.
3. Enter on Line 2 of the voucher the amount shown on Line 1A of the worksheet.
4. Enter on Line 3 of the voucher the amount of your payment shown on Line 1B of the worksheet.
5. Sign the first voucher you file and detach. You need not sign SUBSEQUENT vouchers UNLESS you are amending your estimate.
6. Enclose a check or money order made payable to the Virginia Department of Taxation to the voucher and mail it to the Virginia Department
of Taxation, PO Box 26179, Richmond, VA 23260-6179. PRINT YOUR VIRGINIA TAX ACCOUNT NUMBER ON YOUR CHECK OR
MONEY ORDER. Fill in the following Estimated Tax Payment Record for your own personal tax record.
7. For each SUBSEQUENT installment, enter your payment on Line 3 of the voucher, enclose your check or money order before mailing
it. Be sure to print your Virginia tax account number on your check or money order.
HOW TO AMEND FORM 800ES
If it is necessary to amend Form 800ES, follow these steps:
1. Fill out the Amended Computation schedule below.
2. Enter the revised amounts of estimated tax and payment from Line 4 below on the NEXT voucher due.
3. File online or sign the voucher, detach, and mail with required payment on or before required due date.
4. For each subsequent installment, enter the payment on Line 3 of the voucher, and enclose a check or money order before mailing. Be
sure to print your Virginia tax account number on your check or money order.
Amended Computation
(Use if estimated tax is changed after declaration has been filed.)
Amount
1.
Amended estimated tax. (Enter here and on Line 2 of the
.00
next voucher due.) ................................................................
$
2.
Payments made or credits applied against 2017
.00
declaration .............................................................................
$
3.
Unpaid balance (Line 1 minus Line 2) ..................................
.00
$
4.
Amount to be paid (Line 3 divided by number of remaining
installments). Enter here and on Line 3 of the next
.00
voucher due...........................................................................
$
Page 2
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