Card Type VisaMasterCardDiscoverAmerican Express

Transaction Type CreditDebit

Card Information:

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Billing Address:

Authorization Confirmation:

By entering the credit card information herein, you hereby confirm that you provide authorization for Skyline Insurance to use the above payment method for payment of the policy being applied for, and that the insurance company is authorized to initiate payments from the credit card that you are hereby submitting for premium payments as they become due. Premiums due include but are not limited to premium, policy fees, inspection fees, installment fees or any applicable fees.

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Document name: Credit Card Authorization

Unique Document ID: 36289817d0895ff0acf41bed5e07d667f2ebd86a

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Timestamp	Audit
February 15, 2024 8:33 am MDT	Credit Card Authorization Uploaded by Matthias Allred - [email protected] IP 50.225.25.74

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://skylineinsuranceagency.com/

Audit Trail Serial# 3577cac5077c67110cb829b01d57e983