ACORD 610 Premium Payment Supplement Form | Fillable PDF

ACORD 610 (2003/09)

Premium Payment Supplement

Form Number:

ACORD 610

Category:

Supplementary Forms

Last Updated:

September 2003

Page Count:

01 Page

File Format:

PDF, Fillable PDF

Download Form Fill Form

ACORD 610

The Acord 610, also known as the Premium Payment Supplement, is an official insurance document used to set up and authorize premium payment agreements between the applicant and the insurance company. It provides a clear and structured way to record how premiums will be paid, such as electronic funds transfer (EFT), payroll deduction, or direct billing. The form includes all necessary details about payment frequency, due dates, and authorization for financial transactions. If you’re applying for a new policy or updating your existing payment method, download and fill out the form now to manage your premium payments efficiently and keep your coverage active.

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Benefits of The Acord 610 PDF

Clear Payment Structure

The form outlines various payment frequency options, including annual, semi-annual, quarterly, or monthly payments, allowing flexibility for different financial situations.

Missed or Late Payment Prevention

By clearly defining payment terms and allowing for automatic deductions, the Acord 610 form helps avoid missed payments that could lead to policy cancellation.

Premium Financing Coordination

For applicants who use a premium finance company, this form includes a section to list finance-related information, helping align payment terms between the insurer and the finance company, eliminating errors and confusion.

Key Sections of The Acord 610 Premium Payment Supplement?

Applicant & Agency Information

This section contains agency name, address, codes & subcodes, applicant name, complete mailing address, and company details.

Policy Information

The policy section collects the company name, policy number, and other payment-related information.

Premium Payment Information

It lists available payment frequencies, such as annual, biannual, quarterly, and bi-monthly.

Payment Method

This section lets you select the preferred payment type.

Banking Information

It requires banking or account information, such as ABA routing number, bank account number, account type, etc.

Finance Company Details

It includes information about a finance company.

Employer or Payroll Deduction

For employer-based payments, this section contains the employer name, address, employee ID, and payroll deduction details.

How To Complete The Premium Payment Supplement Form?

  1. Agency Details: Fill in the agency details, including agency name, customer ID, code, and subcode.
  2. Applicant Information: Provide the applicant’s full name and mailing address.
  3. Policy Information: Fill in the policy section, providing the insurer’s name and the policy number related to the payment agreement.
  4. Payment Frequency: Choose how often you want to make premium payments, such as annual, semi-annual, quarterly, bi-monthly, monthly, or custom plans.
  5. Payment Method: Indicate whether payments will be made via verbal check, EFT, payroll deduction, mailed check, or credit card.
  6. Banking Information: Fill in the routing ABA number, bank account number, account type, etc.
  7. Review & Confirm Payment Amount: Specify the total premium amount, number of deductions, and due dates.
  8. Remarks: Provide any extra notes, instructions, or special billing requests.
  9. Signature: The applicant and the producer must sign and date the form to confirm authorizations.
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Frequently Asked Questions

This is used to record and authorize how an insurance premium will be paid. It helps applicants and insurers agree on payment methods, frequencies, and due dates.

The applicant and the insurance producer are required to complete the form. The applicant provides payments and authorization information, while the producer verifies and submits the form.

  • Electronic funds transfer (EFT) from a savings or checking account.
  • Mailed a check payment.
  • Credit card payments.
  • Payroll deduction through an employer.

Of course, the form provides multiple payment frequency options, including annual, semi-annual, quarterly, monthly, or bi-monthly. So, you can choose any suitable payment option.

You have to attach the voided check or deposit slip when setting up an electronic or banking payment.

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