Please complete the information below to provide your banking information for credit card payment processing. Please note, additional forms may be needed per carrier requirements, but this allows at least the initial payment to be made. Please work directly with the licensed agent for additional details.

Questions? Contact us at:

531-222-2120

First Name *

Last Name *

Phone *

Credit Card Company Name *

Please Note: Most insurance companies do not accept American Express at this time. Please reach out with any questions.

Credit Card Number *

Expiration Date (MM/YY) *

Three Digit CVV Number *

Billing Zip Code *

Signature *

Clear

I hereby certify that I am the authorized owner of the account provided above and possess the authority to act on its behalf. By submitting this form, I grant consent to Redinbaugh Enterprises, LLC, its subsidiaries, and its representatives to utilize this banking information exclusively for processing payments related to my insurance policies, upon receipt of a written request. I acknowledge that payments will be directed solely to the relevant insurance carrier(s), and understand that an additional carrier-specific form may be necessary.

By checking this box, I also agree to the Privacy Policy terms, per the company's policy.