Please charge my premium to my VISA, MASTERCARD, or DISCOVER
account
(13 or 16 digits)
VISA
(16 digits)
MASTERCARD
(16 digits)
DISCOVER
CARD NUMBER
EXP. DATE
Amount to be charged $______________________
Policy Number ______________________
Daytime Phone # (___ )____________
MUST
BE SIGNED
TO BE VALID
SIGNATURE
DATE
PLEASE
PRINT
NAME
Please be sure to include this document with your
premium notice so that your payment can be properly applied.
Any premium refunds due to changes or cancellation will be refunded
to your agent.
PEKIN INSURANCE COMPANY
2505 COURT STREET
PEKIN, ILLINOIS 61558-0001
TELEPHONE (309) 346-1161ext 2926 • FAX NO. (309) 478-2175
THE FARMERS AUTOMOBILE INSURANCE ASSOCIATION • PEKIN INSURANCE COMPANY
