Payment Authorization - ACH Bank Account

Payment Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us. This

authorization will remain in effect until cancelled.

Credit Card Information

Card Type MasterCard Visa Discover AMEX Other_______________________

Cardholder Name (as shown on card): _____________________________________________

Card Number : ________________________________________________________________

Expiration Date (mm/yy):___________________________ CVV:______________________

Cardholder Billing Address for card :______________________________________________

ACH/Bank Account

Account Type: Checking Savings

Routing Number: _______________________________________________________________________

Account Number: _______________________________________________________________________

Name on Account: ______________________________________________________________________

I,______________________________, authorize Better Rates Search Group, LLC to charge

the credit card or ACH above on my behalf for an agreed policy premium. I understand that my

information will be saved to file for future transactions on my account.

________________________ _______________________ ______________

Customer Signature Title Date