Assurance Systems
Secure Payment Form - Credit Card

 NOTE: Please double-check your account information before submitting payment!
Online Payment Summary:
Payment Date: 12/18/18
Payment Amount:
Service Description: AccuAuto (rating and management)
AgencyThrive (websites & web marketing)
Customer IP: 
Credit Card Information:      Click here to pay by check
Card Type:

Name as on Card:
Card Billing Address:    (Street address only, NO city/state)
Card Billing Zipcode:
Card Number:
Card Expiration Date: MMYY
Card ID (CVV2/CID) Number:
[What is the Card ID?]
Billing Information:
AccuAuto Account #:
Agency Name:
First Name:
Last Name:
Email Address (for receipt):
By clicking the 'Process Payment' button, you agree with the following terms and conditions: I authorize Assurance Systems, Inc., to debit the bank account or credit card indicated in this web form for the noted amount on today's date. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card or bank account, and that I will not dispute the payment with my Credit Card Company or Bank, so long as the transaction corresponds to the terms indicated in this web form.