Zoom Professional Services

Name*

Email*

Date*

Payment is for:*

Payment Method*

Full Payment Amount:*

Full Policy Number*

Name of Agency on Broker Statement

Please upload copy of the check - Checks must be payable to Zoom Professional Services.

Drop files here or

Max. file size: 512 MB.

Please upload copy of ALL POST DATED installment checks - please read criteria below.

Drop files here or

Max. file size: 512 MB.

Checks must be payable to Zoom Professional Services. Please upload all the installment checks with post dates for future payments.

Name as it appears on the card:*

Full Credit Card Number:*

CC Expiration Month*

CC Expiration Year*

CCV Number:*

Address on Credit Card

Street Address Address Line 2 City State ZIP Code

I agree to the following Payment Plan:*

I hereby authorize Zoom Professional Services to duplicate the attached, or otherwise provided checks, in bank draft form. This authorization is valid for the first transaction installment as well as future installment payments in the amount that has been agreed upon between myself and Zoom Professional Services to satisfy the sum owed to the insurance carrier for the policy number listed above. The transaction amounts will be for exactly the amount listed on each installment check and the checks will be drafted on, or after the dates listed on each installment check. I have read and agree to all of the terms and conditions on this page and any other contract or document that accompanies this agreement. I certify that I am the authorized account holder for this checking account. I understand this is a legal binding agreement between Zoom Professional Services and the undersigned and I will receive a copy of each check draft in my statement when the item has cleared. I also understand that if my item or items, are returned unpaid for any reason, including, but not limited to, NSF, uncollected funds, invalid or closed account, stop payment, or any other reason, the company will attempt to redeposit the item or items, and may choose to assess a returned check charge in the same or separate draft for $25, or the maximum returned check charge allowed in your state.

I agree to the following:*

I hereby authorize Zoom Professional Services to use my Credit Card information provided below. The transaction amount will be for exactly the amount listed above, for payment related to the above-referenced policy. This credit card charge will be debited automatically from my account on a one time only basis. I understand that any late fees accrued on my account will be included in this charge, if not already paid. I acknowledge and understand that I currently have funds available in my account to process this transaction. I have read and agree to all of the terms and conditions on this page and any other contract or document that accompanies this agreement. I certify that I am the authorized account holder for this credit card. I understand this is a legal binding agreement between Zoom Professional Services and the undersigned. I also understand that if my item or items, are returned unpaid for any reason, including, but not limited to, NSF, uncollected funds, invalid or closed account, stop payment, or any other reason, the company will attempt to collect the item or items, and may choose to assess a fee of $15.

Name of party agreeing to above terms*

PLEASE MAIL TO:

Zoom Professional Services 2244 Faraday Ave #129 Carlsbad CA 92008

Agent/Broker Payments

Broker/Agent Payments

PLEASE MAIL TO:

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