Effective Dates: 08/23/2011 - Present Previous | Next

HI 00830.065 Exhibit—Summary Sheet, Installment Payments for Retroactive Premium Due Amounts

SUMMARY SHEET
INSTALLMENT PAYMENTS FOR RETROACTIVE PREMIUM DUE AMOUNTS

CAN                 

 

NAME             

 

COVERAGE PERIOD             to             

 

TOTAL PREMIUMS DUE $             

 

MONTHLY AMOUNT $             

 

FIRST MONTH/YEAR OF INSTALLMENT             

 

LAST MONTH/YEAR OF INSTALLMENT             

Installment No. Month of Installment Amount of Installment Balance Date of Check Received by and Date
 1
 2
 3
 4
 5
 6
 7
 8
 9
10
11 ​ ​ ​ ​ ​
12 ​ ​ ​ ​ ​
13 ​ ​ ​ ​ ​
14 ​ ​ ​ ​ ​
15 ​ ​ ​ ​ ​
16 ​ ​ ​ ​ ​
17 ​ ​ ​ ​ ​
18 ​ ​ ​ ​ ​
19 ​ ​ ​ ​ ​
20 ​ ​ ​ ​ ​

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Summary Sheet - Page 2

INSTALLMENT PAYMENTS FOR RETROACTIVE PREMIUM DUE AMOUNTS

CAN             

 

NAME             

Installment No. ​ Month of Installment Amount of Installment Balance Date of Check Received by and Date
21 ​
22 ​
23 ​
24 ​
25 ​
26 ​
27 ​
28 ​
29 ​
30 ​
31 ​
32 ​
33 ​
34 ​
35 ​
36 ​
37 ​
38 ​
39 ​
40 ​
41 ​
42 ​
43 ​
44 ​
45 ​
46 ​
47 ​ ​ ​ ​ ​ ​
48 ​ ​ ​ ​ ​ ​
49 ​ ​ ​ ​ ​ ​
50 ​ ​ ​ ​ ​ ​
To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600830065
HI 00830.065 - Exhibit—Summary Sheet, Installment Payments for Retroactive Premium Due Amounts - 08/23/2011
Batch run: 03/29/2017
Rev:08/23/2011