FMIC - Billing, Service Charges, Payment

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Billing Information

THERE IS NO CHARGE FOR PAYMENT IN FULL BY AUTOMATIC PAYMENT PLAN, CHECK, CASH, MONEY ORDER OR CREDIT CARD PAYMENT.

PLEASE VISIT OUR WEBSITE TO COMPLETE YOUR CREDIT CARD TRANSACTION, CHECK YOUR PREMIUM, COVERAGES OR OPEN CLAIM INFORMATION.

FMIC Direct Bill Payment Plan … If you elect to use it.

CHOOSE ONE OPTION OF PAYMENT: (You may change your payment method at any time by notifying us.)

#1 ________ Payment in full by check, cash or money orders. NO BILLING CHARGE FOR PAYMENT IN FULL.
4 payments by check, cash or money order. $6.00 Charge for payments other than deposit.

#2 ________ Payment in full by Automatic Payment Plan. NO BILLING CHARGE FOR PAYMENT IN FULL.
4 payments by Automatic Payment Plan. $6.00 Charge for Payments other than deposit.

#3 _______Payment in full by Master Card or VISA. NO BILLING CHARGE FOR PAYMENT IN FULL..
4 payments by Master Card or VISA. ($6.00 Charge for Payments other than deposit). You must request this option for each payment, or use our website to process your payment due to the changes in credit card expiration dates.

ACH Payment Plan (Electronic Withdrawal) OR Credit Card Billing Information

Fulmont Mutual Insurance Company is pleased to announce three methods to pay your premium. *If you choose our electronic Automatic Payment Plan program, we will automatically deduct your insurance premium from your account on your due date to eliminate check writing and save mailing costs. If you use any of our payment options, a service charge of $6.00 will be applied to each Automatic Payment Plan payment, Direct Bill payment or Credit Card payment, excluding the down payment. If you wish to use either of these programs, please complete the following information and return it to us at least 10 days prior to your premium due date. All information will remain confidential, and only necessary personnel will have access to your information.

POLICYHOLDER INFORMATION:
Your name (As it appears on your statement) Your Signature Policy Number _____________________________________________
Your email address ____________________________________________________
Today’s Date _____/_____/_______


Please complete the appropriate section for ACH/Electronic Withdrawal or Credit Card Payment:
ACH (ELECTRONIC WITHDRAWAL) INFORMATION:
Your Bank Transit/ABA #(9 Digits) Bank Name Your Account Number (Found on Lower Left Corner on your Check) _____________________________________________

CREDIT CARD BILLING INFORMATION:

Type of Card – VISA or Master Card Account Number Expiration date:

_____________________________________________

PAYMENT AMOUNT $ ___________ Daytime Telephone #(____)______-______

Your address (As it appears on your statement)

_____________________________________________

Automatic Payment Plan or Direct Bill Payment Plan
Payment Schedule:

- Your 1st payment will be deducted from your account or is due on the effective date of your policy or due date.
- Your 2nd payment will be deducted from your account or is due on the 60th day after the effective date of your policy.
- Your 3rd payment will be deducted from your account or is due on the 120th day after the effective date of your policy.
- Your 4th payment will be deducted from your account or is due on the 180th day after the effective date of your policy.

Service Charge: A service charge of $6.00 will be applied to each Automatic Payment Plan payment, Direct Bill payment or Credit Card payment, excluding the down payment. PLEASE NOTE-A charge back fee of $ 33.00 will apply for any “dishonored” automatic withdrawal or check.

Billing Period: The billing period is the first 180 days after the effective date of the policy.

Endorsements: For endorsements to your policy within the above billing period, please complete this form and return it to us at least 10 days prior to the premium due date. The premium will be split between remaining payments. For endorsements after the above billing period, the premium is due in full by the due date on the bill. In order to avoid service charges, it is suggested that you make the necessary arrangements to pay for any endorsements through this program.

Reminders: If another party is to pay the premium, initial the bill and send it to them. Reminder notices will not be issued. Your agent should handle coverage questions, changes or claims.

A cancellation notice for non-payment of premium will be issued when the bank has dishonored an automatic withdrawal or check. The amount due will be the original premium, plus the bank charge back fee and cancellation fee. This amount will be payable in cash, money order, certified bank check or agency check.

SPECIAL REMINDER: If you choose the Automatic Payment Plan option, you will receive a new bill, listing your payment amounts and due dates. Please keep this new bill in a safe place, as you will no longer be receiving a separate billing for each of the ACH payments due.

Miscellaneous Fees-

Cancellation Fee: If a cancellation notice is issued due to non-payment of premium of this policy, a $25.00 fee will be charged.

Returned Check or Returned Electronic Payment: If a check or electronic transfer payment is returned, a $33.00 fee will be charged. This fee is hinged upon the Schedule of Rates, Fees and Charges utilized by our depository bank. We only reimburse ourselves for the bank charge.

Check Reissue: If a check needs to be reissued at the request of the policyholder, a $25.00 fee will be charged. If a stop payment needs to be issued on the check to be replaced a fee of $32.00 will be assessed in addition to the reissue fee.

Mortgagee Change/Amendment Endorsement Fee: If more than one Mortgagee Change/Amendment Endorsement is issued in a policy period a fee of $5.00 will be assessed for each/every Mortgagee Change/Amendment Endorsement after the first change.

Refunds on Request of Insured Cancellations: All requests for policy cancellation initiated by you, your representative or a premium finance agency will result in any unearned premium or refund being determined in accordance with the applicable short rate table. A pro-rata return of unearned premium or refund will apply to cancellation initiated by you or your representative upon your entry into the military services of the United States or any deletion or reduction of coverage in which the policy continues in force. A pro-rata return of unearned premium or refund will also apply to any cancellation initiated by us.

For questions on your billing or premium please e-mail us at billing@fulmontmutual.com.

For further information regarding our policies, send e-mail to
info@fulmontmutual.com, or write to us at:
Fulmont Mutual Insurance Company
P.O. Box 487, Johnstown, NY 12095-0487