Transcription of PREMIUM PAYMENT SUPPLEMENT DATE …
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PREMIUM PAYMENT SUPPLEMENT DATE …
AGENCY CUSTOMER ID: DATE (MM/DD/YYYY). PREMIUM PAYMENT SUPPLEMENT . AGENCY CARRIER NAIC CODE. POLICY NUMBER EFFECTIVE DATE NAMED INSURED(S). PAYMENT PLAN. BILLING ACCOUNT #: DEPOSIT AMOUNT: $ EST TOTAL PREMIUM : $. BILLING PAYMENT PLAN PAYMENT METHOD MAIL POLICY TO: DIRECT BILL - POLICY FULL PAY BI-MONTHLY CASH PAYROLL DEDUCTION AGENT. DIRECT BILL - ACCT ANNUAL MONTHLY CHECK PRE-AUTHORIZED DRAFT / CHECK (PAC) INSURED. AGENCY BILL SEMI-ANNUAL CREDIT CARD. QUARTERLY EFT. PAYOR PREMIUM FINANCED? FINANCE COMPANY. INSURED MORTGAGEE Y/N. FOR EFT, PAC OR CHECK.
discover visa mastercard american express national producer number (required in florida) producer's signature applicant's signature date producer's name (please print) state producer license no
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