Report And Remittance Form

Overnight Address:

12485 SW 137th Avenue

•

Suite 300

•

Miami, FL 33186

Mailing Address:

PO Box 77-0250

•

Miami, FL 33177-0250

Phone:

1-877-522-7343

•

Fax:

305-234-1774

Report and Remittance Form

Financial American Life Insurance Company (FAMLI) Account Number: __ __ __ __ __ __ __ __

ENDING DATE OF PERIOD COVERED BY THIS REPORT: _______________________ __ _____________

NUMBER OF CERTIFICATES ENCLOSED:

Issued No. ___________________________ __ __ __ _ _________

Cancelled No. _________________________ ______ _ _ _ ______

Total No. ___________ ___________________ ____ _ ___ ______

Helpful Hints

Failure to complete required sections and provide requested information will delay processing of your Business.

Should you have any questions on how to complete the below section(s) feel free to contact us for assistance at 877-522-7343 (press 4)

•

Entering your account number will ensure that your business will be processed promptly and correctly.

•

Separate Life and Disability Premiums/Cancellation amounts into Columns A (Life) and Column B (A/H)

•

Commission percentage may vary depending on coverage.

Before you mail out, make sure you’ve attached the check (if applicable) and all certificates and

cancellation forms (completed) that have been reported below.

Column A

Column B

Column C

Life

Accident & Health

Total

1.

Total of Premium on certificates enclosed

$

$

$

(A1+B1)

2.

Total refund amounts for cancellation enclosed

$

$

$

(A2+B2)

3.

NET WRITTEN PREMIUM – Issues less cancels

$

$

$

(A1–A2)

(B1–B2)

(A3+B3)

(Row 1-2)

4.

YOUR COMMISSION PRECENTAGE %

%

%

5.

YOUR COMMISSION AMOUNT $

$

$

$

(A3xA4)

(B3xB4)

(A5+B5)

(Net Premium X Commission %)

6.

Amount to be sent to FAMLI

$

$

$

(A3–A5)

(B3–B5)

(A6+B6)

(Net Premium less Commission $)

AMOUNT OF CHECK TO BE SENT TO COMPANY $ _______________________________________________________

(Amount from Cell C6)

(Make Check Payable to FAMLI)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Group Policyholder / Dealership / Producer

Contact Name / Finance Manager (Print)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Address (Number and Street)

Contact Phone Number

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

City, State, Zip Code

Contact Fax and/or E-mail Address

Please read important information below.

Please make sure that all certificates and cancellations are complete. Failure to do so will delay processing and may

cause business to be returned. Each certificate/cancellation must include:

• Insured Information (Name, Date of Birth, Social Sec. #, and Address)

• Coverage and premium clearly entered and/or selected.

• Evidence of Insurability Section completed ( if applicable) and Signed.

• Cancellation Form must include cancellation date and refund amount(s).

RR.1 FAMLI (02/11)

WHITE COPY – FAMLI

YELLOW COPY – Agent