Billing Zip Code:( Zip of address at which
you receive your card statement)
*
Security Code:
( 3 digit code on the back of your
card )
*
Payment Amount:
*$
*
Yes, I understand that That there is a online convenience fee of 5
dollar per
hundred in addition to my
premium payment. I also understand that there are NO Agency REFUNDS on credit
card payments. Any
refunds will be sent from the insurance carrier.
*
Yes, I understand that no payment is applied until verified by Insurance Plus,
and that any canceled policy
is
NOT reinstated or in force until confirmation of Payment and that submission of
this payment request
form does not constitute Coverage.
Thank you for filling out Our Quote Request Form!
Disclaimer Notice: - The
premiums quoted are estimates based in the information you provided.
If you have any questions or other pertinent information you feel
necessary to properly quote your insurance Please feel free to phone
us at the number above for a personalized quote.
