Form Dr-908 - Schedule Xv - Filing Fee Schedule (2010)
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1DR-908
R. 01/10
Page 12
Name _____________________________________ FEIN _________________________________ Taxable Year _ _____________
SCHEDULE XV
FILING FEE SCHEDULE
Required Filing Fees
Filing Fees
Fraternal Benefit
Prepaid Limited
Legal Expense
All
Due Per Quarter
and
Societies
Health Service Orgs.
Insurance Corporations
Others
1st Quarter (Due on 4/15/09)
0
$250
1st Quarter
Filing fees must be reported and paid to
the Office of Insurance Regulation.
2nd Quarter (Due on 6/15/09)
0
$250
2nd Quarter
For purposes of this schedule,
3rd Quarter (Due on 10/15/09)
0
$250
3rd Quarter
the filing fees are zero.
4th Quarter
$250
$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
2009 Calendar Year
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 in 2009, 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 Officer (Required)
Date
Name
9100 9 20099999 0016045999 7 3999999999 0000 2
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