Forms

Please complete the fields below to sign up for ACH/EFT Recurring Payments.

Authorization Agreement
I (we) hereby authorize Policy Pal Premium Billing, Inc. to initiate debit entries to my (our) account at the financial institution name below.

This agreement is to remain in full force and effect until Policy Pal Premium Billing, Inc. has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Policy Pal Premium Billing Inc. and financial institution named below a reasonable time to act on it.
Customer (Insured) Information
For internal use only
Customer Name*
First Last
Loan Number*
Customer Email*
Customer Phone*
Account Holder Information
Account Holder Name*
First Last
Name of Financial Institution*
Routing Number*
Account Number*
Checking or Savings*
Checking or Savings?
- Checking
- Savings
Authorized Signature*
Authorized Signature
Authorized Signature 2*
Authorized Signature
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Date
Voided Check Upload
Voided Check Upload
Accepted file types: jpg, png, pdf, Max. file size: 20 MB.

Please complete the fields below to sign up for Debit/Credit Card recurring payments.

Authorization Agreement
I, the holder of the card below, hereby allow Policy Pal Premium Billing Inc. to a recurring charge to my credit/debit card listed below.

This agreement is to remain in full force and effect until Policy Pal Premium Billing, Inc. has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Policy Pal Premium Billing Inc. and financial institution named below a reasonable time to act on it.
Customer (Insured) Information
For internal use only
Customer Name*
First Last
Customer Email*
Customer Phone*
Credit/Debit Card Information
Type of Card*
Type of Card
- Visa
- Mastercard
- Discover
Cardholders Name*
Card Number*
Expiration Date*
CVC Code*
Billing Address*
Billing Address

Address City State ZIP
Authorized Signature*
Authorized Signature
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Date

Please complete the fields below.

Must have at least 3 installments remaining on the note and the additional premium must be over $300.00.
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Date
Insured Name*
First Last
Loan Number*
Policy Number*
Endorsement Number*
Date*
MM slash DD slash YYYY
Pure Premium*
Tax & Stamp Fee*
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Total Additional Premium*
Down Payment*
Amount Financed*
Based on the number of payments made as of date of this request
30% if installment #1 or 2 has been made
40% if installment #3 or 4 has been made
50% if installment #5, 6 or 7 has been made
Agent Signature*
Agent Siganture
Contact Name*
Contact Phone*

Please complete the fields below.

Insured Name*
First Last
Name on Policy*
Policy Number*
Insured Email*
Insured Phone*
Second Insured Phone
Financial Responsibility
This information is accurate and true to the best of my knowledge. I understand I'm responsible for any unpaid balance or processing fees if the policy cancels.
Name of Underwriter*
Name of MGA*
Insured Phone*
Underwriters Email*
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Date

Please complete the fields below.

Authorization Agreement