Paying by Credit Card

Named Insured
Total Due
Name on Card
Card type
Card number
Do not include dashes or spaces
Verification code
Usually in small print on the back of your card
Expiration date
Billing address
City
State
Zip
Phone
Fax
E-mail
I authorize Frazier Insurance Agency, Inc. to charge my credit card in the amount listed above for the insurance as requested by me.
Signature