Payment Authorization

Named Insured

Provide the name of the insured as it appears on the policy

Policy Type:

Payment Type:

Other

Client Number

Authorized Person Signing

First NameMiddle NameLast Name

Amount

Please Select Payment Method

Account Type

Account Holder

ABA Routing Number

Account Number

Type of Credit Card

Credit Card Number

Expiration Month and Year

CVC

Special Notes

I {personSigning13} authorize All City Insurance, Inc. to charge the Credit Card listed above for the amount indicated. I understad that all Credit Cards transactions are subject to an additional 3.5% processing fee.

Disclamer:

Payment is not a guarantee of coverage by the insurance company or All City Insurance, Inc. its agents, producers or employees.

This is a Payment Authorization only, no payment will be processed at this time.

I {personSigning13} authorize All City Insurance, Inc. to debit the Checking Account listed above for the amount indicated.

Disclamer:

Payment is not a guarantee of coverage by the insurance company or All City Insurance, Inc. its agents, producers or employees.

This is a Payment Authorization only, no payment will be processed at this time.