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By submitting this form you authorize S.O.S Insurance Brokerage to draft a check on your bank account for the amount shown below. You will receive a copy of the check in your next monthly bank statement. Payment will be posted on the date of the on-line submission.

You understand a $25 fee will be charged for all checks returned by your bank for any reason, and you authorize S.O.S Insurance Brokerage to bill your account should such an event occur.

I understand that the submission of this payment DOES NOT indicate reinstatement of any lapsed policies. Furthermore, This On-line payment is only considered binding when I receive an email (or fax) response from SOS Insurance indicating that they have received my Payment and the insurance companies have accepted to reinstate my policy.

I Also understand that if this payment is for monthly installments and it is being submitted after the due date, there would be a lapse in coverage and the insurance companies have the option not to accept this payment.

Please provide the following information (Must be the same as address on check)

Check Information

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