Fulmont Mutual Insurance Company

HOME OFFICE:  PO Box 487, Johnstown, New York  12095-0487

    BRANCH OFFICE:  PO Box 300, Canajoharie, New York  13317-0300

visit us @:  www.fulmontmutual.com

 

FMIC Direct Bill Payment Plan … If you elect to use it.

 

Choose one option of Payment:  (You may change your payment method at any time by notifying us.)

#1      ________          Payment in full by check, cash or money order.

                _______ 4 payments by check, cash or money order.

#2      ________                Payment in full by Automatic Payment Plan.  (*Direct Electronic Withdrawals).

_______                4 payments by Automatic Payment Plan.            (*Direct Electronic Withdrawals).

#3      ________          Payment in full by Master Card or VISA.  (Please complete following information below)

________4 payments by Master Card or VISA.    (Please complete following information below)

 

ACH Payment Plan (Electronic Withdrawal) OR Credit Card Billing Information

 

Fulmont Mutual Insurance Company is pleased to announce our three methods to pay your premium. *If you choose our new electronic Automatic Payment Plan program, we will automatically deduct your insurance premium from your account on your due date to eliminate check writing and save mailing costs. The advantage to using this program is there will be no service charge for this new electronic Automatic Payment Plan program.   If you use our Direct Bill or Credit Card payment plan, a service charge of $5.00 will be applied to each Direct Bill payment or Credit Card payment, but not the downpayment.  If you wish to use either of these programs, please complete the following information and return it to us at least 10 days prior to your premium due date.  All information will remain confidential, and only necessary personnel will have access to your information.

 

 

 

POLICYHOLDER INFORMATION:

 

 

____________________________________    ______________________________        _____________________________  ­­­­­ Today’s Date _____/_____/_______     

Your name (As it appears on your statement)    Your Signature                                               Policy Number                                        

 

 

Please complete the appropriate section for ACH/Electronic Withdrawal or Credit Card Payment:

 

 

ACH (ELECTRONIC WITHDRAWAL) INFORMATION:   ______________________________                           ______________________________                                _____________________________ Your Bank Transit/ABA #(9 Digits)                            Bank Name                                                                            Your Account Number (Found on Lower Left Corner on your Check)

 

 

 

CREDIT CARD BILLING INFORMATION:   ________________________________                              __________________________________                          _____________________________ Type of Card – VISA or Master Card                                     Account Number                                                      Expiration date   ____________________________________________________________________                                      Daytime Telephone #(____)______-______ Your address (As it appears on your statement)

Please see reverse for information

 

 

 

 

 

 

 

 

 

 

Automatic Payment Plan or Direct Bill Payment Plan

Payment Schedule:

 

Your 1^st payment will be deducted from your account or is due on the effective date of your policy or due date.

Your 2^nd payment will be deducted from your account or is due on the 60^th day after the effective date of your policy.

Your 3^rd payment will be deducted from your account or is due on the 120^th day after the effective date of your policy.

Your 4^th payment will be deducted from your account or is due on the 180^th day after the effective date of your policy.

 

Service Charge:   There is no service charge for Automatic Payment Plan Payments.  A service charge of $5.00 will be applied to each Direct Bill payment or Credit Card payment, but not the downpayment.  PLEASE NOTE-There may be a charge back fee for any “dishonored” automatic withdrawal or check.  The fee imposed hinges upon the Schedule of Rates, Fees and Charges utilized by our depository bank.  The fee will not exceed $30.00.

 

Billing Period:       The billing period is the first 180 days after the effective date of the policy.

 

Endorsements:    For endorsements to your policy within the above billing period, please complete this form and return it to us at least 10 days prior to the premium due date.  The premium will be split between remaining payments.  For endorsements after the above billing period, the premium is due in full by the due date on the bill.  In order to avoid service charges, it is suggested that you make the necessary arrangements to pay for any endorsements through this program.

 

Reminders:           If another party is to pay the premium, initial the bill and send it to them.  Reminder notices will not be issued.  Coverage questions, changes or claims should be handled by your agent.

 

A cancellation notice for non-payment of premium will be issued when an automatic withdrawal or check has been dishonored by the bank.  The amount due will be the original premium, plus the bank charge back fee.  This amount will be payable in cash, money order, certified bank check or agency check. 

 

SPECIAL REMINDER:  Please note the change to our billing notice.  If you choose either of the above mentioned 4-payment plan options, you will receive a new bill.  Please keep your new bill in a safe place, as you will no longer be receiving a separate billing for each of the payments due. 

 

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