Additional Manual Request

ADDITIONAL PREMIUM REQUEST
Request Date

MonthDayYear
Date
Merit Account #
INSURED
BROKER
PROPOSED ADDITIONAL PREMIUM SUMMARY
Present Balance
if known
Total Additional Premium
Down Payment
as proposed
Amount Financed
Service Charge
if known
Total Amount with Service Charge
Pays Left
if known
New Payment Amount
Next Date Due

MonthDayYear
Date
If this is a New Policy, please add the following information:
a. Policy Number
b. Effective Date

MonthDayYear
Date
c. Insurer
d. Cov. Type
e. Policy Premium
f. Policy Fee
DISCLOSURE: This is a QUOTE only. Actual amounts WILL vary. Submitted quotes are subject to underwriting review. Down payment will be adjusted to zero if Additional is $500 or lower and in other circumstance on underwriting. This Additional shall be accepted only once you receive confirmation with the revised payment schedule that sets out specific amounts.

Please send this Additional Premium Request to Merit no later than 10 days from the Request Date set out above. By sending this page to Merit you agree as Broker to the terms and conditions of the original financing agreement and such terms and execution thereof shall be impliedly and expressly integrated herewith as duly authorized and requested. Further, you agree as Broker that the Insured agrees to be bound herewith in accordance with the same terms thereof. Please send this to support@meritfinance.ca, or, by fax to 902-422-2260 to deliver to Merit.
If this is a New Policy Customer to Sign Here

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