100 LaCosta Lane, Suite 120, Daytona Beach, FL
32114
Phone (386) 274-2600 * Fax (386) 274-4111 * Email: Premium@ebu-inc.com
| Group Name | Case Number | ||
| TPA | Policy Number | ||
| Premium Month | Effective Date |
| Rate Type | Current Count | + or - Adjs (*) | = Adj'd Count | x Premium Rate |
= Specific Premium |
| Single | $ | ||||
| Family | $ | ||||
| Total | $ | ||||
|
Less Commission % (if applicable) |
$ | ||||
|
Net Specific Premium Due |
$ | ||||
(*)
Maximum retro adjustment allowed on any one individual is limited to two months.
(*)
Please make premium check payable to Presidential Life Insurance Company and remit to the address listed above. Thank you.
| No coverage under this policy
will be in effect until the first (1st) premium is paid. For coverage to
remain in effect, each subsequent premium must be paid on or before the
due date. You are responsible for the payment of premiums. Premiums are
not considered paid until the premium payment is received by us. A Grace Period of 31 days from the due date will be allowed for the payment of each premium after the first premium payment. During the Grace Period, the coverage will remain in effect provided the premium is paid before the end of the Grace Period. If you do not pay the premium during the Grace Period, this policy will terminate without further notice retroactive to the date for which premiums were last paid. Please see your policy for complete details. |
(webmpr.aug2006-S5.1)