Credit Card – Check Duplication Authorization Form

Comments

This field is for validation purposes and should be left unchanged.

Complete this section

CREDIT CARD ACCEPTANCE: I authorize Infinity Property & Casualty Corporation to charge my premium payment for my Classic Collectors auto insurance application to my Credit Card.

Policy / Submission Number

Applicant Name

Signature

Date

Name as it appears on Credit Card if Different than above

Address

Day Phone

Evening Phone

CREDIT CARD INFORMATION:

Card Type

VISA

Master Card

American Express

Credit Card Account #

Expiration Date

Amount

Or complete this section:
CHECK DUPLICATION (use for faxed applications only):

I authorize Infinity Property & Casualty Corporation to use this information to create a duplicate check to be deposited in Infinity’s bank account to make premium payment towards my Classic Collectors Auto application.

Bank Name

Routing Number

Address

Checking Account Number

City, ST, ZIP

Check Number

Attach a copy of original check in this space and fax to Classic Collectors Insurance at (888) 783-1470.
No duplicate check will be generated until the approval of your submission.

Copy of check here

Accepted file types: jpg, png, pdf, Max. file size: 10 MB.

Applicant Name

Signature

Date

NOTE: Please send the original application including photos & declarations page for applicants regular use vehicles within 14 days of receiving approval of your submission. Applicant may also send a check or money order made payable to Infinity for payment. We will be forced to cancel coverage if the original application is not received.