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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:
*  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


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 The Travelers Indemnity Company and its property casualty affiliates (“Travelers”) to enroll me in the Recurring Credit Card Payment Plan.  I understand that this authorization allows Travelers to automatically charge the debit/credit card account I have provided for all policy premium and charges, and if necessary credit the account.  I understand that this is a recurring authorization and it applies to future policy renewals, reinstated policies and replacement policies and to policies I subsequently enroll.  In the event of a change to my charge amount or a policy number change, or if policies are added, Travelers will provide advance notice.  The advance notice will identify these changes and be sent prior to the scheduled charge to which the change applies.  I understand this authorization will remain valid until I provide Travelers with notice of cancellation.  I also understand that Travelers and/or my financial institution can cancel my enrollment at any time.  I represent that I am the owner and/or authorized signer on the debit/credit card account.
  *Note: Refunds via credit card are not allowed on policies in the state of Georgia.
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