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For customer service, contact your Agent or call
1-800-964-2532

Billing Statement Date:
xx/xx/xx
Bill Account Number:
xxxxxxxxxx
Membership/Customer Number:
xxxxxxx
Payment Due Date:
xx/xx/xx
Minimum Payment Due:
$$$
Thank you for letting us serve you.

Policy Type Policy Number(s) Policy Term Description Payment Frequency Current Premium Due
Automobile xxxxxxxxxxx xx/xx/xx-xx/xx/xx Vehicle Year / Make /
Model
Monthly
Quarterly
Full Pay
$$$
Current Billing Summary
Premium Due $$$
*Service Charge(s) +     $
*Late Fee(s) +     $
Minimum Payment Due $$$
*See reverse side for explanation.
INVOICE 1 11/10

Bill Account Number:
xxxxxxxxxx
Payment Due Date:
xx/xx/xx
Minimum Payment Due:
$$$
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