ProductionInsurance.com

  A Service of Supple-Merrill & Driscoll, Inc.

 

 

 

 Online Payments

  1. Please be sure to complete each field to submit for payment.

  2. We accept Visa, Mastercard, American Express and Discover.

  3. No transaction will be recorded by submitting this form.

  4. This form is used to provide credit card information to be processed with insurance provider. 

This is a secure form.  Strong cryptography is implemented via the Secure Sockets Layer protocol.  Our Privacy Policy.

  PDF Authorization Form (Fillable)

 

( indicates required information)

Credit Card Authorization
Client or Policyholder Name:
Phone:

Email:

We will never rent, sell, or share your email address.

Policy or Quote Number:
Card Holder Name:
Card Type:
Card Number:

Security Code:

3 Digit Code on Back or 4 Digit Code on Front (AMEX)

Expiration Date:
Billing Address:
Billing City, State: ,
Billing Zip Code:
Total Charge:
Cardholder Signature & Date:

Name of Cardholder

Date

 
Payment Authorization:

By checking this box I understand and agree that coverage cannot be cancelled nor changed once my credit card has been charged. In addition, I agree that there are neither refunds nor charge-backs allowed after my credit card has been charged. All credit card charges are processed through the insurance provider with whom you have accepted terms and coverage.  Accordingly, I understand my credit statement will show the name of the insurance provider, or some variant thereof, as the vendor.

 

Cardholder acknowledges receipt of goods and/or services in the amount of the total shown hereon and agrees to perform the obligations set forth in the Cardholder's agreement with the Issuer.

 

 

 

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ProductionInsurance.com is the entertainment division of Supple-Merrill & Driscoll, Inc.  California License 0517777.

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