Unearned Premium (UEP) Claims

Unearned Premium Form

Please choose to either fill out the online form below or mail a completed paper copy to our office so we can process your Unearned Premium refund. If you choose to mail a paper copy, your refund may be delayed due to the post office. We encourage you to use the electronic form for the fastest processing.

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Using the drop down arrow, please select your previous insurance company (liquidated company).(Required)

Insured's Name(Required)

First Name Last Name

Insured's Phone Number(Required)

Insured's Email Address

Insured's Address(Required)

Street Address Address Line 2 City State ZIP Code

Policy Number(Required)

Upload Your Insurance Policy Declaration Page(Required)

Please upload your insurance policy's declaration page in .pdf, or photo (.png or .jpg) format

Accepted file types: pdf, png, jpg, Max. file size: 25 MB.

Upload Your Proof of Premium Payment Document(Required)

Please upload your proof of premium payment document (receipt) in .pdf, or photo (.png or .jpg) format.

Accepted file types: pdf, png, jpg, Max. file size: 25 MB.

Policy Period Start Date(Required)

Example: 04/28/2017

Month:

Day:

Year:

Policy Period End Date(Required)

Example: 04/28/2018

Month:

Day:

Year:

Date Policy Cancelled(Required)

Example: 04/28/2018

Month:

Day:

Year:

Amount of Policy Premium(Required)

Example: $105.78

Did you already receive an unearned premium payment on this policy that your agent used to lower the cost of your replacement insurance policy?(Required)

Yes

Was your policy premium paid by a finance company?(Required)

Yes

Name of Finance Company (leave blank if not applicable)

Electronic Signature(Required)

Please type your full name

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Unearned Premium Form

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Unearned Premium