CA-AS Payment Transmittal 07/08

License# 0H45142

PAYMENT TRANSMITTAL

Broker Code: ____________ Broker Name: _________________________

DATE: ______________________

NAMED INSURED:________________________________________________ (Last) (First) (Middle Initial)

POLICY NUMBER: _______________ DUE DATE: ____________________

AMOUNT PAID: _________________ CANCELLATION DATE: ___________

______ Installment ______ Renewal ______ Reinstatement (plus applicable reinstatement fee)

• Thoroughly complete this form and fax to (800) 902-7827 and we will debityour trust account via “EFT”.

• If the payment is received after the due date, the Named Insured must signthe following “No Loss Statement”.

No Loss Statement

I certify there have been no losses, accidents, or damage to the vehicle from___________ to ___________. I (we) agree to indemnify All Star

(Cancellation date) (Today’s date) Insurance Agency for any damage or costs as a result of any misrepresentation in this statement.

X___________________________________ Date:___________Time:________ Named Insured’s Signature

X_________________________________________ Broker’s Signature

THIS FORM MUST BE FAXED. DO NOT MAIL. (800) 902-7827