Credit Card Authorization

Credit Card Authorization for Payment of Insurance Premiums

I hereby request and authorize all insurance premiums for my individual occupational accident insurance policy and/or professional liability insurance policy to be deducted from the credit card listed on my application, including any renewal premiums, until I instruct otherwise in writing. I acknowledge that I am the owner or authorized signor on the credit card account and have full rights and privileges to use the account.

I understand that if there are any changes to my insurance policy(ies), the amount of the premium may also change from the above-stated. I acknowledge that, in the event that the direct payment of any insurance premiums by credit card for my insurance policy is rejected or declined for any reason, it will become my personal responsibility to immediately pay the premiums for my individual occupational accident insurance policy and/or professional liability insurance policy or my policy(ies) will be cancelled.

CM&F Group