Form Dr-908 - Computation Of Insurance Premium Tax Page 10
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10DR-908
R. 01/07
Page 12
Name _____________________________________ FEIN _________________________________ Taxable Year ______________
SCHEDULE XV
FILING FEE SCHEDULE
Required Filing Fees
Filing Fees
All
Fraternal Benefi t
Prepaid Limited
Legal Expense
Due Per Quarter
Societies
Health
Insurance Companies
Others
1st Quarter (Due on 4/15/06)
0
0
$25
$250
1st Quarter
2nd Quarter (Due on 6/15/06)
0
0
$25
$250
2nd Quarter
3rd Quarter (Due on 10/15/06)
0
0
$25
$250
3rd Quarter
4th Quarter
$250
$200
$100
$250
4th Quarter
(Due with this return)
✒
Total Filing Fees for the Year. Enter here and on Page 1, Line 9 and Schedule XIV, Line 9, Column A
SCHEDULE XVI
SURCHARGE ON COMMERCIAL/RESIDENTIAL POLICIES
Type of Policy
Total Policies Subject to Surcharge
Rate
Surcharge Due
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.
SCHEDULE XVII
PAYMENT DUE FROM FLORIDA LIFE AND HEALTH
INSURANCE GUARANTY ASSOCIATION (FLAHIGA) REFUND
1. Total Payment Due from FLAHIGA Refunds Received in 2006, 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
CHANGE
Complete this form, sign it, and mail
Mail to:
IN
it to the Department if:
FLORIDA DEPARTMENT OF
Business
Location_________________________________________________________
New
• The address below is not correct.
REVENUE
Location
City____________________________________ State_______ ZIP__________________
• The business location changes.
5050 W TENNESSEE ST
Address
• 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 Offi cer (Required)
Date
Name
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