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Higgins Insurance Agency, Inc  ***  5252 W Irving Park Road Chicago Il 60641
Office: (773) 286-6666 Fax: (773) 286-0228     E-mail: higginsauto @ sbcglobal.net
Credit / Debit Card Authorization For Higgins Insurance Agency, Inc
Select Card Type:    Visa  Mastercard  Discover
Card Number: Card Expiration Date:   ##/##
Amount To Charge: Card Security Code:
Card Holder's Name:
(Person Card Was Issued To)
Statement Street Address:
City: State: Zip Code:
Daytime Telephone: Today's Date:   ##/##/####
E-Mail Address:
Policy Holder's Name:
(Insured's Name)
Policy Number(s) or
Contract Number:
Not Required (Optional)

This form authorizes Higgins Insurance Agency, Inc. to process a one time charge for the amount indicated above to the credit/debit card provided. This form does not authorize future charges or automatic payments. The policy holder and credit card holder understand that a newly completed authorization is required for every credit/debit card transaction. The terms and conditions of this form have been read and are understood by all those concerned.
I authorize Higgins Insurance Agency, Inc. to charge the amount indicated above to the credit/debit card provided.


CALL (773) 286-6666 TO CONFIRM RECEIPT OF AUTHORIZATION.
PAYMENTS ARE CONSIDERED RECEIVED WHEN THEY ARE APPLIED TO THE ACCOUNT.
AUTHORIZATION IS NOT VALID UNLESS COMPLETED IN FULL.

OR if you prefer, you may complete form, , sign, and submit by fax to: (773) 286-0228

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          Authorized Card Holder's Signature