Please do not submit premium financed payments through this payment page All financed premium payments must be submitted directly to the finance company Financed payments that are submitted through this page will be refunded Please email caitlyn@anthonyinsuranceservices.com to request the online link for financed premium payments Description of Insurance being purchased todayIf making changes to the policy, (i.e. increasing the general aggregate limit, adding Independent Contractors, adding back additional coverage for tournaments/hosted events, etc.) please make note of the requested policy change/addition in the above field. If adding back coverage for Independent Contractors, please provide the name, mailing address and additional premium of $75.00 for each instructor to be added.Name of Policyholder*Please enter the name of the policyholder as it appears on your policy documents or the coverage enrollment form. Payment Amount* Name* First Last Email Phone*Billing Address*Please enter the billing address (i.e. where your credit card billing statements are sent) for the credit card Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
