Form Dr-907 - Florida Insurance Premium Installment Payment
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1
2
3DR-907
HD/PM Date:
/
/
Florida Insurance Premium Installment Payment
R. 01/15
US Dollars
Cents
FEIN
Florida Code
,
,
1. Premium tax payable
2. Surcharge
,
,
a. commercial policies
Business Partner Number
# _________________ x $4
DR-907
,
,
b. residential policies
# _________________ x $2
Payment Number 1 Tax Year
,
,
3. Interest
Due April 15
,
,
4. Penalty
Name
,
,
5. Quarterly statement filing fee
Address
City/St/ZIP
,
,
6. Amount due
Do not write in the space below.
o
Check here if you made your payment electronically.
Be sure to sign and date reverse side.
9100 0 20159999 0016045033 2 3999999999 0000 2
DR-907
HD/PM Date:
/
/
Florida Insurance Premium Installment Payment
R. 01/15
US Dollars
Cents
FEIN
Florida Code
,
,
1. Premium tax payable
2. Surcharge
,
,
a. commercial policies
Business Partner Number
# _________________ x $4
DR-907
,
,
b. residential policies
# _________________ x $2
Payment Number 2 Tax Year
,
,
3. Interest
Due June 15 (Estimate premiums through June 30)
,
,
4. Penalty
Name
,
,
5. Quarterly statement filing fee
Address
City/St/ZIP
,
,
6. Amount due
Do not write in the space below.
o
Check here if you made your payment electronically.
Be sure to sign and date reverse side.
9100 0 20159999 0016045033 2 3999999999 0000 2
DR-907
HD/PM Date:
/
/
Florida Insurance Premium Installment Payment
R. 01/15
US Dollars
Cents
FEIN
Florida Code
,
,
1. Premium tax payable
2. Surcharge
,
,
a. commercial policies
Business Partner Number
# _________________ x $4
DR-907
,
,
b. residential policies
# _________________ x $2
Payment Number 3 Tax Year
,
,
3. Interest
Due October 15
,
,
4. Penalty
Name
,
,
5. Quarterly statement filing fee
Address
City/St/ZIP
,
,
6. Amount due
Do not write in the space below.
o
Check here if you made your payment electronically.
Be sure to sign and date reverse side.
9100 0 20159999 0016045033 2 3999999999 0000 2
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Parent category: Financial