Payment Form 05/15/2015
Signature: ________________________________________________ Date: ___________________________________
Insured’s Name
Account Billing Address
City State Zip
Email Phone
I understand that this authorization will remain in e ect until Petersen International Underwriters receives a written request from me to
cancel my automatic withdrawal at least 3 days prior to the next scheduled withdrawal or until Petersen International Underwriters elects
to cancel this agreement. I understand that if two or more deductions are not honored, Petersen International Underwriters has the right
to discontinue my enrollment in the Electronic Funds Transfer Payment Plan. I hereby authorize Petersen International Underwriters to
debit my account for the correct installment premium on the due dates of the installments. I understand that my coverage is not in e ect
until all requirements have been submitted and approved by Petersen International Underwriters. I acknowledge that the origination of
EFT transactions to my account must comply with the provision of U.S. law.
P A F
Insubuy, Inc.,
4200 Mapleshade Ln., Suite 200, Plano, TX 75093
Phone (866) INSUBUY • Fax (972) 767-4470 • info [at] insubuy.com
Expiration Date:
/
Routing #
Account #
Card #
Checking
Saving
Option 1) Electronic Check
Select Account Type:
(Must be a U.S.
Bank
Account)
(9-digits)
Security Code:
3
Digit
Code
4
Digit
Code
Option 2) Check - Please make checks payable to Petersen International Underwriters
Option 3) Credit Card
One Payment Only: $____________
Pre-Authorized Annual: $____________
Pre-Authorized Semi-Annual (Annual x .55): $____________
P
r
e-Authorized Quarterly (Annual x .285): $____________
Pre-Authorized Monthly (Annual x .086)*Credit Card and EFT only $____________
M
ulti-Year Single Payment: $____________
Attach Voided Check
