autotech protect remittance form

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Dublin, Ohio43017 Dealer Date Address DealerA ccount# PeriodEnding P reparedBy N o. VSC Eff. Date ContractHolder VehicleInformation (last8ofvin) Class CoverageL evel CoverageCost Total Surcharges F& IM anager TotalCost 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 N ew BusinsesTotal N o. CancellationDate CustomerN ame 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. 5 Cancellation A m ount CancellationTotal( -) N ew BusinessTotal( +) N etR emitT otal P. O .Box 2085 M akecheckspayableto AmericanColonialAdministration, LLC andM ailto: AmericanColonialAdministration, LLC 425 M etroPlaceN orth, S uite500 For questions please contact American Colonial Administration, LLC at 855-807-2885 CAN CELLATI ONS 1 2 3 AdministrativeO ffices 4 S AL ES R EGI ST ER

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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

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

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.

5

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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2

3

Adm inistrativeO ffices

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S A L ES R EGIS T ER