Renters Insurance Electronic Payment Consent

By completing this form, you agree to receive and pay your renters insurance premiums through electronic payment methods. Please read the following terms carefully before providing your consent.

Electronic Payment Authorization

• You authorize the insurance provider to electronically debit your account or charge your credit/debit card for premium payments.
• The payments will occur on the scheduled due dates as specified in your policy.
• You may withdraw your consent for electronic payments at any time by notifying the provider in writing.

Electronic Documents & Communication

• You agree to receive payment notifications, receipts, and related documents electronically.
• You are responsible for ensuring your contact information is accurate and up to date.

Your Information

Name Email Address Policy Number

I consent to electronic payments and communications as described above.

Date