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 InstallmentAmount of InstallmentBalanceDate of CheckReceived by and Date
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Summary Sheet - Page 2

INSTALLMENT PAYMENTS FOR RETROACTIVE PREMIUM DUE AMOUNTS

CAN             

 

NAME             

<
Installment No. Month of InstallmentAmount of InstallmentBalanceDate of CheckReceived by and Date
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