Credit Card Authorization

This form authorizes CalComp Insurance Services, Inc. (Ca. Lic. #OD91096) to charge a non-refundable down payment for the insurance application requested by and for the transferee whose signature appears on the form.
In order to complete this form, the following information is required:

1. Credit Card Number
2. Credit Card Security Code
   (AMEX–4 digits on right front of card above card # /Other–Last 3 digits of number on back strip of card)
3. Credit Card Expiration Date (MM/DD/YR)
4. Name as appears on Credit Card
5. Amount of Charge
6. Date of Charge
7. Authorized Credit Card Signature

Download "Credit Card Authorization" Form