Checking Account Payment Ability to Make Payment 1Payer Information2Check3Credit Card Payer Information Payment Ideal Insurance Agency Inc dba 1st American State Agency Complete this form and we will process your payment. No payment will be processed until information is reviewed and approved by agency staff. Insured Name(Required) Name on PolicyInsured Company Name - If applicable Enter company name on/will be on policyPayor Name(Required) Person - First & Last Name of person payingPayment for(Required) Auto - Personal Policy Business Auto Policy Business Owner Policy Cabin Policy General Liability Policy Home Policy Professional Liability Policy Workers Compensation Other / Not Listed How to Pay - Credit Card or Checking Account(Required) Checking Account Email(Required) Email Address to send Payment ReceiptContact Phone(Required)Contact Telephone NumberPolicy Number (If known) Optional If you know your policy number enter here, if not we can look up for you, if new policy just leave blankNotesGive information or instructions to staff Checking Account InformationName of Checking Account(Required) Name on the checking account for making payment.Zip Code of Checking Account Holder(Required) Zip Code on statement sent to insuredPayment Amount from Checking Account(Required)Payment Amount to be taken from Checking AccountRouting Number(Required) 9 Digit number identifying bank, on checksAccount Number(Required) Number identifying individual bank account, on check Credit Card InformationName of Credit Card(Required) Name on Credit CardZip Code of Credit Card Account Holder(Required) Zip Code on statement sent to insuredCredit Card Type(Required) Visa Mastercard Discover American Express Credit Card TypePayment Amount from Credit Card(Required)Payment Amount to be taken from Credit CardCredit Card Expiration Date(Required) Expiration Date on card ##/## or ##/####Credit Card Security Number(Required) 3 or 4 digit Security Number on Christ CardCredit Card Number(Required) Number on Credit card number Δ
