Common Contracts

COMMERCIAL PREMIUM FINANCE AGREEMENT AND DISCLOSURE STATEMENT

August 5th, 2005

• Filed
  August 5th, 2005

INSURED/BORROWER (Name and address as shown on Policy) A Total Premium $ Telephone Number: Direct Correspondence to: B Cash Down Payment Required $ C Unpaid Premium Balance $ D Documentary Stamp Tax(only applicable in Florida) $ E Amount Financed (The amount of credit provided on your behalf) $ AGENT or BROKER (Name and Business Address) F FINANCE CHARGE(Dollar amount credit will cost you) $ G Total of Payments (Amount you will have paid after making all scheduled payments) $ ANNUAL PERCENTAGE RATE(Cost of your credit figured as a yearly rate) % PAYMENT SCHEDULE BELOW, or See Schedule Attached LENDER FIRST INSURANCE FUNDING CORP.450 Skokie Blvd, Suite 1000P.O. Box 3306 Northbrook, IL 60065-3306Telephone: (800) 837-3707Fax: (800) 837-3709 Number ofPayments Payments are due Amount of EachPayment Prepayment The Insured may prepay the full amount due and Late A late charge will be imposed on any payment which is not receive a refund of the unearned interest as provided Payment r