Allen Financial Insurance Group/The Equestrian Group 12424 N 32
nd
St., Suite 101 • Phoenix, AZ. 85032
SIGNATURE PRINT ____________________________________ DATE ______________
Subscription ID #: _________________________________ Payment ____ of ____ Payment
__________________
Auto EFT/Payment Authorization
*
Brokerage accounts must be paid by agency trust check. A 2.5% fee will be charged against producer commission account on any authorized exceptions.
A.F.I.G. Account #: ______ _____ Policyholder: _____________________________________________
Broker (If Applicable): _____________________________ Policy #: ________________________________
Contact Phone #:_______________________ Email Address:_______________________________________
--Payment Options--
**
Pay Plans are not offered on all policies and must be approved before binding of coverage. Minimum premium of $500 eligibility requirement
for Pay Plans. The following are Ineligible for Pay Plans: Short-Term policies, Special Event policies, policies that are fully earned, and any
policy that is required by the Insurance Company to be paid in full at inception and/or before coverage can be bound.
Full Payment: $____________ premium + tax/fees.
Monthly Pay Plan: ___% of premium + taxes/fees down payment; followed by __ installments (+ inst. Fees)
Down Payment: $
Date: Amount: $
Date: Amount: $
Date: Amount: $
Date: Amount: $
Date: Amount: $
Checking Account Credit Card
Checking
*photo copy of physical check required
Name on Acct ____________________________
Bank Name ____________________________
Account Number ____________________________
Bank Routing # ____________________________
Starting Check # ____________________________
Visa MasterCard Amex
Cardholder Name ____________________________
Billing Address ____________________________
____________________________
Account Number ____________________________
Exp. Date ________ CVV Code _______
I/We agree that, if this authorization is sent to you by facsimile or by any other means, you may act upon it whether or not you receive an
original hard copy. I/We authorize Allen Financial Insurance Group to collect payment through Electronic Funds Transfer from a financial
institution or approved credit card or bank account. I understand that the inability of Allen Financial Insurance Group to make this collection will
result in immediate cancellation of my insurance policy. I/We also agree that by this I/We are guaranteeing payment in full of the above-
mentioned insurance policy and other related services; including, but not limited to endorsement premium. I understand that this authorization
will remain in effect until the expiration of my policy’s current term and I agree to notify Allen Financial Insurance Group, Inc. &/or The
Equestrian Group in writing of any changes in my account information at least 15 days prior to the next billing date. If the above noted payment
dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For payments made from my
checking account, in the case of the check being rejected for Non Sufficient Funds (NSF) I understand that Financial Insurance Group, Inc. &/or
The Equestrian Group may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25.00 charge for
each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I certify that I am an
authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or Credit Card Company. In
addition, Allen Financial Insurance Group &/or The Equestrian Group have my authorization to Automatically process payment with this
information for any additional premium, tax & fees not listed in the above schedule that generate from an endorsement that I requested in
writing.
*REQUIRED - photo copy of physical check and driver's
license of authorized signer on account.
