1.  Today's Date:

2.  Your Company Name:    
     Your Name:
     Your Title:
     Phone Number: (xxx-xxx-xxxx)   Ext.
     Email Address:

3.  Type of Inquiry -- click box and number corresponding to your inquiry:
        1  Confirm sending of Finance Agreement and Deposit Payment
        2  Confirm sending of Finance Agreement payment
        3  Question About KBS Invoice or Statement
        4  Correction to KBS Invoice or Statement
        5  Need help clearing up overdue balance 
        6  Confirm payment made to KBS
        7  Request total balance due
        8  Other

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Confirmation of Sending -- Finance Agreement & Deposit:

1.    Date Sent:

2.    Method of Sending: Overnight Delivery 2nd-Day Delivery First-Class Mail Wire Transfer Other

3.    Amount Financed or Total of Premiums: $
        optional -- refer to finance agreement 

4.    Each page of Finance Agreement signed?   YES   NO
       Original signature sent?    YES   NO

5.    Amount of Check: $
       Check number (optional):

6.    KBS should confirm receipt?   YES   NO    

7.    Special instructions?   Comments?
      

       Finished -- Ready to Submit

Confirmation of Sending -- Finance Agreement Late Payment:

1.    Date Sent:

2.    Method of Sending: Overnight Delivery 2nd-Day Delivery First-Class Mail Wire Transfer Other

3.    Original Due Date:
        optional -- refer to finance agreement 

4.    Check sent to Finance Co.? (NOT KBS)   YES   NO
       Payment included late charges?   YES   NO

5.    Amount of Check: $
       Check number (optional):

6.    Special instructions?   Comments?
      

       Finished -- Ready to Submit

Question About KBS Invoice or Statement:

1.    "Item" Number: refer to the left-hand column on your invoice or statement

        Alternatively, if the Item Number is not known, please provide:
        Invoice Number:   or  Statement Date:

2.    Amount in Question: $  
            Type of Policy (optional): 
            Policy Number (optional):

3.    Payment already sent to KBS?   YES   NO

4.    Please state your Question(s):  (be specific and use as much space as you need)
      

       Finished -- Ready to Submit

Correction to KBS Invoice or Statement:

1.    "Item" Number: refer to the left-hand column on your invoice or statement

        Alternatively, if the Item Number is not known, please provide:
        Invoice Number:   or  Statement Date:

2.    Amount in Question: $  
            Type of Policy (optional): 
            Policy Number (optional):

3.    Payment already sent to KBS?   YES   NO

4.    Please describe the Correction(s):  (be specific and use as much space as you need)
      

       Finished -- Ready to Submit

Help Clearing Up Overdue Balance:

1.    Have you received Notice of Cancellation?   YES  NO
        If so, date cancellation will take effect:

2.    Is problem related to a Finance Agreement?   YES  NO

3.    Amount Past Due (as best you understand it):  $

4.    Payment Schedule Preferences:  Single Check -- little/no penalty Limited Payments over 30-60 days (lower penalty) Extended Payments (higher penalty) Other -- explain in "Comments" box

5.    Contact Preferences:  Email Call -- early morning Call -- mid-day Call -- afternoon Call -- late Fax Other -- describe in "Comments" box

6.    Special instructions?   Comments?
      

       Finished -- Ready to Submit

Confirmation of Sending -- Payment to KBS:

1.    Date Sent:

2.    Method of Sending: Overnight Delivery 2nd-Day Delivery First-Class Mail Wire Transfer Other

3.    Amount of Check: $
           Check number (optional):
           Type of Policy (optional): 
           Policy Number (optional):

4.    Billing "Item" Number: refer to left-hand column on invoice or statement

        Alternatively, if the Item Number is not known, please provide:
        Invoice Number:   or  Statement Date:

5.    KBS should confirm receipt?   YES   NO    

6.    Special instructions?   Comments?
      

       Finished -- Ready to Submit

Request Total Balance Due:  

1.    Level of Detail:  Simple Total Figure Total and Breakout of Individual Items Other -- explain in "Comments" box

2.    Provide your balance as of which date?

3.   Comments / Special Instructions:
     

       Finished -- Ready to Submit

Other Inquiry:  Describe your needs.  Please be as specific as possible.
    

            Return to Client Services  (do NOT submit)