Figure: 28 TAC §13.9(e)


DAILY COLLECTION SHEET
(DATE)
Policy
No.		 Name
of
Insured		 Cash
Collected		 Amount
Retained
by Agents		 Membership Fee Regular
Premium
Month
(1st, 2nd, etc.)		 Amount
 

            


PREMIUM CARD
Face of Card
Insurance Age:

Insured:

Address:


 Year of Issue:

Beneficiary:

Address:
Policy No.           Date of Policy Amount of Policy $               
                              Mo. Day Year
Date of Birth		                     Mo. Qt. S.A. Ann.
     Premium:
REMARKS:


  


Back of Card
Amount of Premium $ __________________
Year:

19		 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
19                        
19                        
19                        
19                        
19                        


Income (left side)

I N C O M E
          Regular Premium Other Income Bank Deposit
Date Explanation Total
Collected		 Retained
By Agents		 Membership
Fee		 Mortuary
Fund		 General
Fund		 Mortuary
Fund		 General
Fund		 Mortuary
Fund		 General
Fund
 



                    


b. Disbursements (right side)

D I S B U R S E M E N T S
Date Payee Name
of Bank		 M O R T U A R Y    F U N D G E N E R A L    F U N D
Checks Written Distribution Checks
Written		 Distribution
Check
No.		 Amount Claim Claim
Expense		 Check
No.		 Amount Agents
Commissions		 Officers
Salaries		 Employees
Salaries		 Travel
Expense		 Ins
Dept
Fees		 Taxes
&
Rent		 Print
Adv &
Stat.		 Post
Tel
Telg.		 Other
 




                                  


4. Policy Register

P O L I C Y    R E G I S T E R
Policy
No		 Name
of
Insured		 Beneficiary Date
Policy
Issued		 Insured's
Date
of Birth		 Amount
of
Benefit
Amount of Premium		 REMARKS
Name Address Mo. Qt. S.A. Ann.
 



                      


5. Claim Register

C L A I M    R E G I S T E R
Claim
No		 Name of
Insured		 Beneficiary Policy
No.		 Date
of
Policy		 Date
of
Death		 Date
Proof
Filed		 Date
Paid		 Amount
of
Policy		 Amount
Paid		 REMARKS
Name Address