autotech protect remittance form
DESCRIPTION
ÂTRANSCRIPT
Dublin,O hio43017
Dealer Date
Address DealerAccount#
P eriod Ending
P repared By
N o.VS C Eff.
Date ContractHolder
VehicleInform ation
(last8ofvin) Class CoverageL evel CoverageCost
T otal
S urcharges F&IM anager T otalCost
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N ew BusinsesT otal
N o. CancellationDate Custom erN am e ContractN um ber
Make checks payable to American Colonial Administration for amount in Net Remit Total.
Attach check(s), cancellations and registrations to Sales Register.
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Cancellation
Am ount
CancellationT otal (-)
N ew BusinessT otal(+)
N etR em itT otal
P .O .Box 2085
M akecheckspayabletoAm ericanColonialAdm inistration,L L C andM ailto:Am ericanColonialAdm inistration,L L C
425 M etroP laceN orth,S uite500
For questions please contact American Colonial Administration, LLC at 855-807-2885
CA N CEL L A T IO N S
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Adm inistrativeO ffices
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S A L ES R EGIS T ER