By submitting this form, you acknowledge that you are paying a fee owed on the existing insurance policy listed above. You also acknowledge that you are aware that your broker charges a $5.00 nonrefundable payment processing fee. If there has been a lapse in coverage, there may be additional fees and/or other additional forms that need to be filled out.

I have read and agree to the terms mentioned above.

 
Please make a note of the total amount owed before you continue!