Common Contracts
1 similar Insurance Premium Finance Agreement contracts
ContractInsurance Premium Finance Agreement • October 31st, 2002
INSURANCE PREMIUM FINANCE AGREEMENT ACCOUNT NUMBER P.O. Box 105611 • Atlanta, GA 30348-5611(678) 498-4700 • (800) 925-2546 • FAX (678) 498-4747 • www.siuprem.com ❒ PERSONAL❒ COMMERCIAL ❒ NEW ❒ RENEWAL❒ ENDORSEMENT INSURED SSN# AGENT AGENT # MAILING ADDRESS TAX ID# ADDRESS RISK LOCATION CITY - STATE - ZIP CITY - STATE - ZIP PHONE PHONE PREFIX AND POLICY NO. EFFECTIVE DATE EXPIRATION DATE TERM FULL NAME OF INSURANCE CO / BRANCH OFFICE ADDRESS NAME AND ADDRESS OF GENERAL AGENT IF ANY COVERAGE TYPE POLICY PREMIUM FEE TAX FEE TAX In consideration of the payment by SIUPREM, INC. (hereinafter referred to as SIUPREM) of the A MOUNT FINANCED of the premium described above for my account and on my behalf, I hereby accept the following terms and conditions:1. I agree to repay to SIUPREM the TOTAL OF PAYMENTS (The amount paid after making the scheduled payments) in accordance with the payment schedule shown below. I agree to make the FIRST PAYMENT DUE on tim
