For every premium collected on a policy of property, casualty, life, or accident and health insurance in this state, the agent collecting or receiving such a premium shall:
(1) Furnish the payor with written evidence of payment at the time the premium is collected, which shall include the amount paid, the date paid, the date-paid-to status of the policy, the policy number or the identifying characteristics for which the payment will be credited, the signature or signed initials of the agent, and the office address and phone number of the insurer; and
(2) Remit to the insurer's home office or applicable district office the premium collected within ten (10) days of receipt from the premium payor or policy owner.