Incline Casualty Company PREMIUM DUE NOTICE

Administered by: Embark General Insurance Agency, LLC PERSONAL AUTO POLICY
License# L108040
Phone: (833) 362-2751
P.O. Box 500050
Sandy Springs, GA 31150-0050
www.EmbarkGeneral.com

Policy Number Effective Date – Expiration Date Due Date Bill Method / Pay Plan Producer Code
IFL0029221-00 08/21/2023 – 02/21/2024 09/21/2023 6-month 25% Dn, 4 Inst FL182409

Insured Name and Address Contact Information

MARIO ALFONSO SIERRA Univista LLC dba Univista Insurance-FL182409
7045 SW 17TH TER 6505 SW 8th St
MIAMI, FL 33155 Miami, FL 33144
(305) 639-8988

Premium Due Notice (Aviso de Prima Debido)

A payment is now due on your auto insurance policy. Payment of at least the Minimum Due shown below must be received
by us prior to the Due Date shown above. If you prefer to pay your policy in full, that amount has also been indicated below.
Please note that if your payment is returned by your bank due to non-sufficient funds or is otherwise invalid, your policy will
be cancelled.

Esto es su saldo de cuenta. El pago debe ser recibido por nosotros antes de la fecha de vencimiento. Por favor tome en
cuenta que si su pago es devuelto por su banco debido a fondos no-suficientes o es de otro modo invalido, su póliza de
aseguranza cancelara automáticamente. Los planes de financiación incluyen honorarios de procesamiento de pago. Si
prefiere pagar su póliza en su totalidad, la cantidad requerida está indicada abajo.

Minimum Due (Pago Minimo): $98.62

Pay In Full (Pago Completo):

Future Installments – Due dates and amounts are subject to change

Description Amount Due Date Description Amount Due Date
6-month 25% Dn, 4 Inst $98.62 9/21/2023 6-month 25% Dn, 4 Inst $98.64 12/22/2023
6-month 25% Dn, 4 Inst $98.62 10/22/2023
6-month 25% Dn, 4 Inst $98.62 11/21/2023

Failure to maintain personal injury protection and property damage liability insurance on a motor vehicle when required by law
may result in the loss of registration and driving privileges in this state; which can result in a nonrefundable reinstatement fee of
$150 for the first reinstatement, $250 for the second reinstatement, and $500 for each subsequent reinstatement during the 3
years following the first reinstatement.

Please be aware that texting or using your phone in a non- hands free manner while driving is illegal and could result in fines
and jeopardize your insurance coverage. Protect your life and insurance – Don’t text and Drive.

TEAR HERE
Premium Due Notice
Please return this stub and include the policy number on your payment. All installment plans include processing fees.

Policy Number: IFL0029221-00 TO MAKE A PAYMENT: By phone (833) 362-2751 or online

www.embarkgeneral.com
Named Insured: MARIO ALFONSO SIERRA
Credit card payments are processed through a third-party
Enclosed Amount: _____________ payment processor, One Inc. A $4.95 fee will be included in the
total amount charged to your amount.
Due Date: 09/21/2023
Please make checks payable and remit to:
Minimum Due: $98.62
To Pay in Full: Incline Casualty Company
P.O. Box 500050
Sandy Springs, GA 31150-0050

Administered by: Embark General Insurance Agency, LLC LIC#L108040

IFL-1004 06/21 Insured Copy Date of Notice: 08/21/2023

08212023 IFL0029221-00 0000000

MARIO SIERRA eSign: 8/21/2023 7:41 AM CDT, IP: 2600:1700:2a70:a50:51c5:e39a:51b3:11e7