Fill and Sign the Premium Finance Agreement and Disclosure Statement Form

PREMIUM FINANCE CONDITIONS , and its assigns shall `hereinafter be referred to as "the Company". In consideration of the payment to the insuring companies by the company of the amount financed, the undersigned Named Insured promises to pay to the order of the company at its address shown above, the total of payments in successive monthly installments as shown herein. The obligations of the Named Insured hereunder are subject to the following provisions: 1. The undersigned named insured agrees in the event of default in payment of any installment due hereunder or breach of any other term hereof, that unless such default or brea ch is cured within ten (10) days after the company has mailed written notice of its i ntent to cancel the policies to the Named Insured at the address shown above, the company may request from the insurers cancellation of the policies. 2. Upon default for a period of 10 days or more in the payment of any installment herein that he/she shall pay a delinquency charge of % of the amount of the delinquent instal lment, or dollars ($ ), whichever is greater, provided the delinquent installment is more than days past due and that such late payment may be collected only once on each del inquent installment. 3. In the event default in any payment results in cancellation of the policies, t hat upon receipt by the company of any unearned premiums due under the polices, the unpaid balance due hereunder less any unearned portion of the service charge shall automatically become immediately due and payable without notice or demand. Any unearned premiums and divide nds, or either of them payable under the policies to or on behalf of the Named Insured shall be credited to the unpaid balance due hereunder and any excess over such unpaid balance sha ll be paid to the Named Insured, except no refund shall be required if the amount is less than $1.00. The Named Insured shall remain liable to the company for any deficiency plus all c ost of collection, including reasonable attorney's fees. 4. In the event the unpaid balance due hereunder is prepaid in full at any time before maturity of the final installment, the Named Insured shall receive a refund credit or payment equal to the unearned portion of the finance charge computed on the basis of Rule of 78's. 5. The named insured warrants that every representation made by him4 in connection with his/her application for the policies is true and accurate. If for any reason the premium s of any policies are increased by the insureds, the company, upon written request by the named i nsured and receipt of any additional down payment required by the company shall include the bala nce of such increase as an additional obligation owed by the Named Insured to the company under the terms of this agreement. 6. Notwithstanding the provisions of the Notice to insured" set forth below, the names of the insurers issuing the policies and the policy numbers, if omitted herein, may be insert ed in this agreement after it has been signed. 7. Neither the Company nor its assignee or transferee shall have any responsibility or liability to anyone in connection with or arising or accruing as a result or by reason of t he issuance of (or failure to issue) any policy(ies) of insurance. 8. As security for the prompt payment hereof, the undersigned Named Insured hereby assigns, sets over and transfers to the Company all unearned premiums, dividends, and loss payments which may become due and payable under the above described policy(ies) of insurance. The Company is hereby authorized and empowered to cancel the above described policy(ies), and the insurer under said policy(ies) shall then pay to the Company any refund due thereon. In such event the Company shall return the above described policy(ies) to the applicable insurer for cancellation and exchange therefor. The Company shall not be l iable for any loss or damage which may accrue to the insured property after such cancellation of said insurance. 9. In the event of a loss or claim under the above described policy(ies) before this Note is fully paid, the Company is granted a lien on the proceeds of such insurance, subject to a ny prior lien thereon; and the insurer is hereby authorized and directed to pay to the Company the full interest in the proceeds of such loss to the extent of the balance due on this Note, and the Company shall elect to cancel the above described policy(ies) under the procedures provide d herein, it shall promptly advise the Named Insured at the last known address of the Name d Insured, and the Company shall thereafter have no responsibility or liability to the undersi gned Names Insured whether such notice is actually received or not. The Company is fully authoriz ed and empowered to execute all necessary instruments to the insurer on behalf and in the name of the Names Insured to entitle and enable it to receive and enjoy all benefit s and rights under said policy(ies), as aforesaid, and the Company is vested with full and plenary power and authority so to do. POWER OF ATTORNEY: The Named Insured hereby irrevocably appoints , and its assigns, Attorney-in-fact, with full authority, in the manner prescribed by applicable laws, to c ancel the policies listed, or any renewal or rewrite thereof, to receive all sums assigned t o the company and to execute and deliver on behalf of the undersigned all documents, forms and notices rela ting to the policies listed in furtherance of this agreement. The Power of Attorney is coupled with an interest and cannot be revoked to the extent of the authority granted herein. NOTICE TO THE INSURED: 1. DO NOT sign this agreement before you read it or if it contains bland spaces. 2. You are entitled to a completely filled-in copy of this agreement. 3. Under the law, you have the right to pay off in advance the full amount due hereunder and under certain conditions to obtain a partial refund of the service charge under the Rule of 78's method.