The information below is provided for making payments toward your insurance policy.
Name of Client on Policy or 1st Named Insured
First Name
Last Name
Email
example@example.com
Cell #
Client ID #
Do you want to pay
Paid In Full by Card
Auto Payment Monthly done by Card
Payments Monthly Mailed In down payment done by Card
2 Payments by Mail - down payment done by card
The agent knows the payment plan option to use
Information Below is for Using your Bank Account
Name of Client on Policy or 1st Named Insured
First Name
Last Name
Is the Bank Account a
Checking
Saving
Do You Want want to pay
Paid In Full by Checking or Savings
Auto Payment Monthly done by Checking or Savings
Payments Done Monthly by Mail - Down Payment by Checking or Savings
2 Payments by Mailed - Down Payment by Checking or Savings
The agent knows the payment plan option to use
The policy is not bound until you sign the application and receive confirmation that the policy is in force. The agent will use the above information to process payment and issue the policy.
Signature
Submit
Should be Empty: