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CREDIT CARD AUTHORIZATION Date I please print name authorize Gaslamp Insurance Services to charge my insurance premium/taxes/fees to my American Express Visa Mastercard or Discover Credit Card listed below POLICYHOLDER INFORMATION INSURED NAME DBA ACCOUNT TYPE PAYMENT TYPE CREDIT CARD INFORMATION American Express Visa Mastercard Discover CREDIT CARD NUMBER EXPIRATION DATE SECURITY NUMBER ACCOUNT NAME BILLING ADDRESS BILLING CITY STATE CA ZIP AMOUNT AUTHORIZED Signature I understand that I presently have these funds available in my account to process this transaction. This is to be done on a one-time only basis. This transaction is for the payment type only. All future installment premiums will be directly billed by mail to the insured each month by the carrier or premium finance company. PLEASE FAX THIS FORM TO 800 920-4107 card payments is 4. 95 or 4 of the amount charged whichever is greater. 800-920-4125 tel 800-920-4107 fax 1111 6th Avenue 3rd Floor San Diego CA 92101 license 0D80816 www. This transaction is for the payment type only. All future installment premiums will be directly billed by mail to the insured each month by the carrier or premium finance company. PLEASE FAX THIS FORM TO 800 920-4107 card payments is 4. 95 or 4 of the amount charged whichever is greater. PLEASE FAX THIS FORM TO 800 920-4107 card payments is 4. 95 or 4 of the amount charged whichever is greater. 800-920-4125 tel 800-920-4107 fax 1111 6th Avenue 3rd Floor San Diego CA 92101 license 0D80816 www. This transaction is for the payment type only. All future installment premiums will be directly billed by mail to the insured each month by the carrier or premium finance company. PLEASE FAX THIS FORM TO 800 920-4107 card payments is 4. 95 or 4 of the amount charged whichever is greater. 800-920-4125 tel 800-920-4107 fax 1111 6th Avenue 3rd Floor San Diego CA 92101 license 0D80816 www.

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Keywords relevant to Gaslamp Insurance

  • dba
  • policyholder
  • premiums
  • installment
  • TEL
  • billed
  • Expiration
  • premium
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