Payment Authorization

Named Insured *

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

Client Number

Authorized Person Signing *

First Name Middle Name Last Name

Amount *

Please Select Payment Method *

Checking Account Credit Card

Account Type *

Checking Commercial Checking Personal

Account Holder *

ABA Routing Number *

Account Number *

Drivers License No. *

Type of Credit Card

Visa or MasterCard American Express Discovery

Credit Card Number OLD *

Credit Card Number *

Expiration Month *

Expiration Year *

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.

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.

I authorize All City Insurance, Inc. to use this payment authorization for all future insurance-related payments including but not limited to New Policies, Renewals, Endorsements, Audits, Monthly Payments and Installments.