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Recurring Credit Card
  Payment Plan Enrollment
 
Please complete the information below.
You may choose the charge date that fits your schedule.
Charges cannot be made on the 29th, 30th, or 31st.
 
NOTE: This plan is not available for your NY Special Auto policy with Travelers.
 
  Personal Information
*  Name:
Address:
*  City    * State     * Zip 
*  Phone ()  -
Please list the policies that you would like to pay with your credit card.
*  Policy No. 1:
Policy No. 2:
Policy No. 3:
  Credit Card Information
* 

Select One:       Visa®         MasterCard ®

* 

Credit Card Number         * Expiration Date (MMYY)

* 

Select Charge Date(1st-28th only):

 
* 

Select Charge Frequency      Monthly      Lump Sum

How did you learn about Recurring Credit Card?


*  Asterisk indicates required information.
  Authorization for Recurring Credit Card Payments
 By choosing the "Accept" button, I authorize Travelers** to enroll me in the recurring payment plan I selected on this form and to charge my insurance premium for the policy number(s) listed above, including any applicable service charges, directly to my credit card as I have indicated.  I understand that this is a recurring payment plan which means I authorize Travelers to continue to charge my insurance premium in this manner for future policy terms until I provide Travelers with written cancellation.  I understand that Travelers and/or my financial institution can cancel my enrollment at any time.  I further authorize Travelers to make refunds, if any, directly to my credit card when applicable.
 
  *Note: Refunds via credit card are not allowed on policies in the state of Georgia.
  **The Travelers Indemnity Company and its property & casualty affiliates.
                                          
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