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Disclaimer:
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)

I have read and agree with the above

Name on Check

Address

City

State

Zip Code

Phone Number

Email Address

Check Information

Bank Name

Bank City

Bank State

Fraction Code (Located at top right of check.)

Routing Number

Account Number

Check Number

Check Date

Enter The TOTAL amount being paid

Payment To Down Payment Promisory Note Up Rate Monthly Installment

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