Credit Card Authorization - Fax

This authorization is to be used in conjunction with our previously transmitted enrollment form

 

Enrollment Date

Agency Name

Email Address

Current Charge Authorized: $39 Set up +  Monthly fee = Amount Due Credit Card  Visa   AmEx   MasterCard  Name as it appears on credit card  Credit Card Number   Exp Date mm/yy

Amount: (Enter amount before faxing)

Authorized by: X ______________________________________________ Please sign before faxing

Name:

 

This fax page does not transmit electronically!

Complete the information -

Print and fax this page to: 1-410-363-8218

 

to:

InsuranceQuote.net, Inc.

8 Greenspring Valley Rd.

Owings Mills, MD 21117

410-363-2636

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