Payment Authorization Your First NameField is required!Field is required!Your Last NameField is required!Field is required!Your AddressField is required!Field is required!Apt #, Suite #Field is required!Field is required!CityField is required!Field is required!- select a state -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming- select a state -Field is required!Field is required!ZipcodeField is required!Field is required!Your Phone NumberInvalid phonenumber!Invalid phonenumber!Your E-mail AddressField is required!Field is required!Credit CardACHField is required!Field is required!Credit Card Number(^5[1-5]|^4|^3[47])|(^6011|65|64[4-9]|622(1(2[6-9]|[3-9]d)|[2-8]d{2}|9([01]d|2[0-5])))d+[{"field":"{PAYMENT_TYPE}","logic":"equal","value":"credit_card","and_method":"","field_and":"","logic_and":"","value_and":""}]enter a valid card numberenter a valid card number[{"field":"{PAYMENT_TYPE}","logic":"","value":"credit_card","and_method":"and","field_and":"","logic_and":"","value_and":"","new_value":""}]- Expiration Month -01020304050607080909101112- Expiration Month -[{"field":"PAYMENT_TYPE","logic":"equal","value":"credit_card","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!- Expiration Year -202220232024202520262027202820292030- Expiration Year -[{"field":"{PAYMENT_TYPE}","logic":"equal","value":"credit_card","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Security Code[{"field":"PAYMENT_TYPE","logic":"equal","value":"credit_card","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required![{"field":"PAYMENT_TYPE","logic":"","value":"credit_card","and_method":"and","field_and":"","logic_and":"","value_and":"","new_value":""}]Rounting Number[{"field":"{PAYMENT_TYPE}","logic":"equal","value":"ahc","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required![{"field":"{PAYMENT_TYPE}","logic":"","value":"credit_card","and_method":"and","field_and":"","logic_and":"","value_and":"","new_value":""}]Account Number[{"field":"{PAYMENT_TYPE}","logic":"equal","value":"ahc","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required![{"field":"{PAYMENT_TYPE}","logic":"","value":"credit_card","and_method":"and","field_and":"","logic_and":"","value_and":"","new_value":""}]Enter Payment AmountField is required!Field is required!Additional instructions (optional)[{"field":"{PAYMENT_TYPE}","logic":"equal","value":"credit_card","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Additional instructions (optional)[{"field":"{PAYMENT_TYPE}","logic":"equal","value":"ahc","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!I attest that I am an authorized user of the account above, and I authorize Insurance Express and its agents to charge this account for the amount specified on this form. Field is required!Field is required!Field is required!Field is required!Submit
