Laserfiche WebLink
Supple -Merrill & Driscoll, Inc. <br />550 EI Dorado Street • Pasadena, CA 91102 <br />(626) 795-9921 • Fax: (626) 577-6656 • Email: david@productioninsurance.com <br />Credit Card Authorization <br />Production Company <br />Quote Number <br />Card Holder Name <br />Type: (Visa/Mastercard/ <br />Amex/Dismver) <br />Card Number <br />Expiration Date <br />Billing Zip Code <br />Billing Address <br />Signature <br />Fast Carrier/Regenerate <br />22808 <br />Premium <br />3,233.90 <br />Policy Fee <br />225.00 <br />Broker Fee <br />150.00 <br />Convenience Fee (0.0%) <br />0,00 <br />Total charge <br />3,608.90 <br />Cardholder acknowledges receipt of goods and/or <br />services in the amount of the total shown hereon <br />and agrees to perform the obligations set forth in the <br />Cardholder's agreement with the Issuer. <br />By signing this form I understand and agree that coverage cannot be <br />cancelled nor changed once my credit card has been charged. <br />In addition, I agree that there are no refunds nor charge -backs allowed <br />after my credit card has been charged. All credit card charges are <br />processed through Burbank Insurance Agency. Accordingly, I <br />understand my credit statement will show Burbank Insurance <br />Date <br />For Internal Use Only <br />Approval Number <br />All credit card charges are processed through Burbank Insurance Agency. Accordingly, I <br />understand my credit statement will show Burbank Insurance Agency as the vendor. <br />)�W� See attached page for Coverage Explanations. <br />Sample policy available online at www.shorttermproductions.com <br />Coverage will not be bound until receipt of full payment and company approval. <br />Coverage cannot be cancelled nor amended once bound <br />License #: 0517777 <br />