CREDIT CARD

AUTHORIZATION FORM

Please complete this form to authorize Peak Insurance to make a payment using your credit card directly to the Insurance Carrier. 

Authorization To Charge Credit Card

I, authorize Peak Insurance to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the amount indicated above, and is valid for one-time use only. Peak Insurance will use the credit card information to make a payment directly to the insurance carrier on your behalf. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company, so long as the transaction corresponds to the terms indicated in this form.