Dublin,O hio43017

Dealer Date

Address DealerAccount#

P eriod Ending

P repared By

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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