Credit Card Payment Authorization Form

Policyholder's Name:

Policy No./ Nos.

For Straight Charge: Visa MasterCard JCB American Express

Amount to be charged: P

Cardholder's Name :

Credit Card Number :

Expiration Date (MM/DD/YYYY): / /

If Cardholder is not the Insured, please fill out t he following additional information:

Cardholder's Full Name :

Relation to the Insured :

CSG Form No. 5**This form should be accompanied by the cardholder's photocopy of any valid ID or credit card to be used with signature.

Please charge the total amount of the premium indicated abouve to my credit card per option applied for.

I hereby agree to pay the above total amount according to the Card Issuer Agreement. The card company may approve or reject my request at its sole discretion"

Cardholder Details (Write in BLOCK letters)

Credit Card Provider (Put an 'X' mark on the prefer red credit card company)

Credit Card Details

(Last Name, Given Name, Middle Initial)

Policyholder's Signature / DateCardholder's Signature / Date