Name of InsuredCompany NameEmail Amount Paying Account Type*Personal CheckingBusiness CheckingPersonal SavingsBusiness SavingsRouting No.*Account No.*Check No. (Optional)Name on Account* First Last Name on Account*Phone Associated with Account*Total $0.00 Terms and Conditions I hereby agree to payment for the Payment Amount and authorize stated above and warrant all information given is true. I further understand that this transaction is non-refundable and will not dispute the payment with the check issuing bank. I understand that payment for the total amount will not be processed instantly and processing of total amount my take up to 5 days. I also understand that if my payment or payments are returned unpaid for any reason, including, but not limited to NSF, uncollected funds, invalid or closed account, stop payment, or any other reason not listed, Coral Point Insurance Services will attempt to redeposit the items, and may choose to assess a returned check charge of $25.00 in the same or separate draft.Do You Agree to the Terms & Conditions?*Yes, I agreeSignature*
