Auto Insurance Premium Payment Authorization Form
Policyholder Name
Policy Number
Phone Number
Email Address
Payment Amount
Payment Method
Bank Account
Credit Card
Bank Name / Card Issuer
Account Number / Card Number
Routing Number / Expiry Date
Authorization Start Date
Payment Frequency
One-Time
Monthly
Quarterly
Annually
I hereby authorize the insurer to initiate the payment as per the details above.
Signature
Date