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

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