Premium Past Due Report Details

Premium Administrator

Name of the entity administering the premium.

City

Premium administrator city.

State

Premium administrator state.

Fax Number

Premium administrator fax number.

Report Period

Time period the report covers.

Gross Premium

Gross premium due for the report period.

Amount Received

Premium amount received for the report period.

Balance Due

Premium still due for the report period. Difference between gross and amount received.

Receipt

Date of the most recent premium receipt in the reporting period.