Payment Form

I authorize AJM Insurance Management to charge the credit card indicated in this authorization form according to the terms outlined below. I understand that AJM Insurance will charge me a 2% service charge for this transaction. This payment authorization is for the goods/services described below, for the amount indicated below only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

Personal Information

First Name
Required

Last Name
Required

Street
Required

City
Required

State
Required

select

ZIP / Postal Code
Required

Primary Phone Number
Required

E-Mail Address
Required

Policy Number
Required

Credit Card Type
Required

select

Credit Card Number
Required

Security Code
Required

Expiration Date
Required

Payment Amount
Required

Any Additional Information
Optional

Do you understand and accept the 2% service charge for this payment?
Required

select

Enter Validation Code

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

Insurance Websites Designed and Hosted by Insurance Website Builder