AGENTS:  You must keep a signed copy of this form in your files to provide proof to the credit card company that the insured did request this charge.  If the charge is disputed and you do not have it in your file, we will not be able to provide proof that they requested the use of their card, and the monies will be removed from our account, and we in turn will have to charge your office in order to get the payment back.  That will result in your office being responsible for payment.

If you have any questions, please contact our accounting department at (860) 628-3967.