Scott Carter Insurance Agency On-Line Form for Payment by Check

  • FYI-This form will be processed without our having to re-type it. Please add a note in the comment field below if you would like information about this check processing software.
    To send Insurance Premium INSTANTLY by check, just fill out this form and click submit at the bottom of the form.

    Company name (optional)

    Your first name

    Your last name

    Address

    City

    State or Province

    Zip

    Phone

    Best time to call

    Fax (optional)

    Your E-Mail address
    We must have an email address to give you instructions and acknowledge your order.

    These CHECK fields are REQUIRED!

    Account Holder's Name on the Check

    Check Number (record this check in your check book)

    Name of Bank

    City and State or Province where Bank is located

    Fractional ABA number (for USA banks only - looks like 91-210/1225

    9 digit Bank Routing or Transit Number (all funds are US Dollars)

    Your Account Number (include spaces and hyphens)

    Amount of Check

    WARNING: YOUR ORDER WILL NOT BE PROCESSED IF THE LITTLE BOX BELOW IS NOT CHECKED!

    Check this box if ...

    I am paying by check and I have filled in all of the check information fields above - I authorize You to use Version 3.0 software to print a check on my bank for the above selected items in the amounts shown. I understand that the check will show up just like any other check on my monthly bank statement. I also authorize you to draft my account electronically for the face amount of this check AND appropriate returned check fees if my check is returned unpaid. 
    THANK YOU FOR CHECKING THE LITTLE BOX TO PROCESS!

    Please give us your comments:

    We like to know our customers. If you would like us to take a look at your web site, please give us the URL. Thank You.

    We must have your name and an email address to give you instructions and acknowledge your order.

     
    (Please make sure the form is complete and accurate and 
    NOTE
    that there will be a $25 charge for dishonored checks.
    )