I authorize Cabrillo Coastal General Insurance Agency, LLC to charge the checking/savings account or credit card indicated above in this authorization form according to the terms outlined.

I understand this is an electronic transaction and these funds may be drawn from my account as soon as the transaction date listed on the transaction reminder forms.

In the event a transaction is rejected due to insufficient funds, I understand that Cabrillo Coastal General Insurance Agency, LLC may at its discretion attempt to process the charge again within thirty (30) days, and agree to an additional disclosed fee charge for each attempt returned for insufficient funds that will be initiated as a separate transaction from the authorized payment.

If the scheduled payment falls on a weekend or holiday, I understand the payment may be executed on the next business day.

The payment authorization is to remain in full force and effect until I notify Cabrillo Coastal General Insurance Agency, LLC of its cancellation by sending written notice at least fifteen (15) days prior to payment date in order to provide Cabrillo Coastal General Insurance Agency, LLC a reasonable opportunity to act on it.

I agree to notify Cabrillo Coastal General Insurance Agency, LLC in writing of any changes to my account in writing at least fifteen (15) days prior to the next billing date.

This payment authorization is for my insurance premiums due to my Insurance Carrier.

I certify that I am an authorized user of this account and I will not dispute the scheduled payments to Cabrillo Coastal General Insurance Agency, LLC, with my credit card company or bank provided the transactions correspond to the terms indicated on this form.