On-Line Credit Card Payment 

  

Date: // FORMAT (01/01/2002)
Customer Account Number
First Name:
Last Name:
Email Address
Daytime Phone:   -  -  Ext.
Nighttime Phone:   -  -  Ext.
Insurance Company:
Policy Number:
Credit Card Number
Expiration Date Month   Year 
Payment Amount: $


By submitting this form, you acknowledge that you are paying a fee owed on the existing insurance policy listed above. You also acknowledge that you are aware that your broker charges a $5.00 nonrefundable payment processing fee. If there has been a lapse in coverage, there may be additional fees and/or other additional forms that need to be filled out.

 

I have read and agree to the terms mentioned above.

 
Please make a note of the total amount owed before you continue!

 

 

 

 
 

[  Home  | Allen Financial |  Equestrian Group | Am Equestrian |  Am Recreation |  Site Map ]

Contact Information

Phoenix, AZ  -  Home Office (602) 992-1570   Toll Free (800) 874-9191
Del Mar, CA (619) 866-4482   Portland, OR  (503) 608-4820
         
FAX (602) 992-8327   P.O. Box 6230  Scottsdale, AZ   85261
     

General Information: ballen@eqgroup.com              Customer Service: mpallante@eqgroup.com
Mortality: apoling@eqgroup.com                               Entertainment: entertainment@eqgroup.com                   Webmaster: ballen@eqgroup.com