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 |
|
|
|
|
|
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 |
|
|
|
|
|
|