Signature Support
Providing Authorization by Digital Signature for Merit
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Merit Account Number
Insurance Brokerage
Date
-
Month
-
Day
Year
Date
Authorizing Signature to the Following (check as may apply)
Premium Financing Contract
Additional
for Pre-Authorized Payment (PAD)
for Continuous Plan
for Modification
for Credit Card or Debit Card
to change Insurer
Other
Describe what the Signature should be Acknowledging and Confirming
By Applying Signature This Authorizes Merit to place this signature on the applicable document as signed based on the person signing acknowledging to have read and understood the agreement.
Optional File Upload to Specify What Signature Pertains to
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of
for digital signature to be applied to Merit documentation as fully authorizing
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