Credit Card Authorization | Somerset Insurance Solutions

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization form will remain in effect until cancelled.

Card Type*

MasterCard
Visa

Cardholder Name (as shown on card)*

First Last

Card Number*

Expiration Month*

Expiration Year*

CCV*

Cardholder ZIP Code (from credit card billing address)*

Email Confirmation (receipt will be sent to this address)*

Enter Email Confirm Email

By confirming your email address, you authorize Somerset Insurance Solutions, Inc. to charge your credit card above for the agreed upon insurance premium payment.