Insurance Premium Notice

INSURANCE PREMIUM NOTICE

Insurer Name:     Insurer Address:

Insured / Applicant Name:

Date of Notice: Month Day Year

Policy Details

Policy Number:     Policy Type:

Policy Period From: Month Day Year    To: Month Day Year

Base Premium: $

Collision Coverage — Premium: $

Comprehensive Coverage — Premium: $

Liability Coverage — Premium: $

Uninsured Motorist / Other — Premium: $

Subtotal Premium: $    Discounts / Credits: - $

Endorsements / Endorsement Premium: $    Policy Taxes & Fees: $

Total Premium for Policy Period: $

Amount Due

Previous Balance: $    Payments Received: - $

Balance Before Late Fee: $    Late Fee (if applicable): $

Total Amount Due: $    Due Date: Month Day Year

Payment Options

Please remit payment using one of the following methods (select applicable):

Check or Money Order    Electronic Bank Transfer    Credit / Debit Card    Automatic Withdrawal (ACH)

Important Notice — Nonpayment and Cancellation

This notice is provided pursuant to the policy terms. If Total Amount Due is not received by the Due Date, the insurer may assess a late fee, apply interest, suspend coverage, or cancel the policy in accordance with the policy provisions and applicable law. Cancellation for nonpayment will be effective on the date stated in the policy cancellation provision. The insurer's acceptance of a late payment does not constitute a waiver of the insurer's right to enforce cancellation provisions for prior delinquencies unless expressly waived in writing.

If you dispute this amount, you must provide written notice to the insurer within ten (10) days of receipt of this notice identifying the basis of the dispute. Submission of a dispute does not suspend the insurer's right to assess late fees or to cancel the policy if payment is not received when due.

Exclusions and Policy Controls

Coverage under the policy is subject to the terms, conditions, limitations, and exclusions set forth in the policy contract. This notice does not modify, expand, or limit the policy beyond the terms contained in the policy documents. Standard exclusions may include, without limitation, losses caused by intentional acts, wear and tear, war, and nuclear hazard. Refer to your policy for a complete statement of exclusions.

Beneficiary Information

Declaration and Certification

I certify under penalty of perjury that the information contained in this Insurance Premium Notice is true and correct to the best of my knowledge. I acknowledge receipt of this notice and understand the premium amount due, the due date, and potential consequences of nonpayment including cancellation or suspension of coverage. I authorize the insurer to apply payments toward the amounts due and to process payment methods selected above.

I further acknowledge that this notice is an administrative statement of premium due and does not constitute an amendment to or replacement of the policy. The terms and conditions of the policy control in the event of any inconsistency.

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