EmailMe Form - Credit Card or EFT

Step 1: About You

Name *

First Last

Business Name

Mobile Phone *

### - ### - ####

By entering your phone number you agree to receive text from Vantage Point Risk.

Email *

Billing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Step 2: Policy Type: *

Start New Policy

Update Existing Info

Policy Type: *

Home

Auto

Business

Other

Other Policy to Start:

Start New Policy: *

As Quoted

Specific Start Date

Date: *

MM / DD / YYYY

Step 3: Payment Method *

Credit Card

EFT / ACH

Name on Card *

First Last

Card Type *

VISA

Mastercard

Discover

AMEX

Credit Card *

Billing ZIP *

Account Holder Name *

First Last

Bank Name *

Routing Number *

Account Number *

Account Type: *

Step 4: Payment Option *

Pay In Full

Monthly Installments (may incur monthly service fee)

Step 5: Authorization

*

I authorize Vantage Point Risk Partners LLC to securely share my payment information with the insurance carrier for the purpose of initiating or updating my insurance policy billing. I understand that this form does not process any payment and is solely for secure data collection.

Signature: *

Clear

Date: *

MM / DD / YYYY

Single Line Text