Payment Receipt | Meridian Insurance

Payment Information

Client

Date

Policy Number

Carrier

Payment Method

Routing Number

Account Number

Billing Type

Applied Payment

$

Processing Fee

$

Total Payment

$

Policy Details

Policy Type

Carrier

General Agent

Payment Received By

Funds Received By (Accounting)

Date Received By Accounting

Payment Purpose

Purpose

Down Payment on New Policy Payment on Existing Policy

Policy Number

Account Number

Amount

$

Disposition of Funds

Fund Dispositions

Funds Deposited in MI Trust Account MI Trust Account Check Issued Funds Electronically Swept from MI Trust Account Initiate Electronic Sweep from MI Trust Account Carrier Charged Customer Credit Card/Bank Acct Carrier Billing Insured Directly Carrier Billing Mortgagee Directly

Agency Bill Reconciliation

Premium Amount

$

Taxes & Fees

$

Total

$

Payment Received

$

Commission Retained

$

Amount to Company

$

Amount Financed

Financed By

Agency Bill Entered Date

Commission Paid Date

Commission Paid Check #

Special Instructions