Invoice Payment

Order Information

Company name:	Customer ID:	New
First name*:	Last name*:
Phone:	Alt phone:
Email:	Alt email:
Policy Number:

Payment Information

Invoice number:
Payment amount:
Recurs:
Payment date:

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Echeck (ACH) accounts (optional)

Bank name*:
Bank routing number ( ABA The American Bankers Association routing number is a nine digit bank code, used in the United States to identify financial institutions. )*:
Bank account number ( DDA DDA (Demand Deposit Account) is a bank account. )*:
Account type*:
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Billing Address

Address 1*:
Address 2:
City*:
State/Province*:
Country*:
ZIP/Postal Code*:	Help Do not use spaces when entering ZIP/Postal Codes

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Terms and Conditions

I authorize the company named on this web form to debit the bank account or credit card indicated in this web form, for the noted amount on today's date. This payment is for the goods and services noted on the web payment form. I understand that returns, refunds and cancellations are not permitted, however exceptions may be made on a case-by-case basis. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. I agree that payments for billing schedules with common bill dates may be consolidated into a single payment. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that the company named on this web form may at its discretion attempt to process the charge again within 30 days. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card or bank account, and that I will not dispute the payment with my Credit Card Company or Bank, so long as the transaction corresponds to the terms indicated in this web form.

I accept the terms and conditions

INSUREPOINTE OF TEXAS INC
2909 HILLCROFT ST STE 200
Houston, TX 77057
(713) 964-0022
accounting@insurepointe.com
http://www.insurepointe.com

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