RECURRING CREDIT CARD CHARGE AUTHORIZATION AGREEMENT

By clicking on the “Accept” button below, I hereby authorize TruAssure Insurance Company to charge the credit card indicated above on or about the 27th of each month for my monthly premium payment (if the payment method selected is monthly). I understand that the initial credit card charge will occur immediately and if I have selected an annual payment option, the initial credit card charge will reflect the annual premium.

I agree that this authorization will remain in full force and effect until TruAssure has received written notification from me that I am terminating it, and I must give TruAssure at least 25 days prior written notice to terminate this authorization or to change the designated credit card.

I understand that TruAssure will notify me in advance of any changes to the charged amount. By completing this form, I hereby authorize TruAssure and the credit card company identified above to process the charges authorized here. I also authorize TruAssure to make any charges on a future policy I may purchase from TruAssure on the same credit card if I give verbal consent to TruAssure

If I am not the insured person under this policy, I confirm that I am agreeing to pay this insurance premium on behalf of the insured person. Unless the insured person is a minor for whom I am a parent or legal guardian, I understand that any changes to the policy that may affect the charge amount will be communicated to the insured person only.

I agree that if I have any problems or questions regarding this authorization or my insurance policy, I will contact TruAssure for assistance at 888-559-0781. I also agree that I will not dispute any charges with my credit card company without first making a good faith effort to resolve the dispute directly with TruAssure. I guarantee that I am the legal card holder for this credit card and that I am legally authorized to enter into this Recurring Credit Card Billing Agreement with TruAssure.

I authorize TruAssure to make any charges on a future policy I may purchase from TruAssure on the same credit card if I give verbal consent to TruAssure. Further, I understand that any transaction that is dishonored by my credit card company intended for payment to TruAssure may be assessed a $25 service charge by TruAssure.

FOR INDIVIDUALS IN ALL STATES BUT KANSAS: I understand that any transaction that is dishonored by my credit card company intended for payment to TruAssure may be assessed a $25 service charge by TruAssure. Further, I authorize TruAssure to make any charges on a future policy I may purchase from TruAssure on the same credit card if I give verbal consent to TruAssure.

FOR INDIVIDUALS IN KANSAS: I understand that if my credit card company dishonors any transaction requested by TruAssure under this agreement, subsequent payment of any premium due will not keep the Policy in force, except as provided in the Grace Period. If any premium due is not received by TruAssure before or at the end of the Grace Period, the Policy will automatically terminate at the end of the period for which the last premium was paid. Further, I authorize TruAssure to make any charges on a future policy I may purchase from TruAssure on the same credit card if I give verbal consent to TruAssure.
 

BE SURE TO PRINT AND KEEP A COPY OF THIS FORM FOR YOUR RECORDS.