APG INSURANCE SERVICES

PREMIUM FINANCE WORK SHEET

 

DATE:

IS THIS AN ADDITIONAL PREMIUM: [  ] YES  [  ] NO

ACCOUNT Nš

AGENCY

INSURED

CONTACT ADDRESS
ADDRESS
CITY CITY
STATE STATE
ZIP ZIP
TEL TEL
FAX FAX
POL# POL#
EFFECTIVE DATE EFFECTIVE DATE
CARRIER CARRIER
p
p
GEN'L AGENT GEN'L AGENT
TYPE OF COV TYPE OF COV
PREMIUM PREMIUM
TAX/STMP TAX/STMP
POLFEE POLFEE
BKR FEE BKR FEE
TERM: 9 PAY / 10 PAY TERM: 9 PAY / 10 PAY
p
PRODUCER FEE

PRODUCER FEE

MIN EARNED