EMERGENCY CUSTOMER RECEIPT (When System Goes Down)

EMERGENCY CUSTOMER RECEIPT (When System Goes Down)

IMPORTANT - When the system is back up you MUST go to your office email for all receipts and enter receipt into Agency Matrix. Be sure to put a memo in Matrix notes under customer profile that this was done through the agent portal due to our system being down.
Payment Error - If you get redirected to an error page after attempting to process a transaction click the "Back" button (all information will still be there, just re-enter card number and CVC code) and adjust any errors outlined in red. Once errors are corrected you will be able to process the payment.
Office and Agent Information
Store Name: *
Ex: Aiport@Fox Plaza
Store Address *
Street address
Agents Full name *
Store Email *
example@example.com
Customer Details
Customer Name: *
Customer Phone number *

Area Code Phone Number
Customer Email *
example@example.com
Policy Expiration Date

Month Day Year
Date
Payment Details
Type of transaction *

Renewal Endorsment Reinstatement Rewrite New Policy
Type of Agency Service fee *
How is payment being received *
Payment Method *
Premium $ *
Agency Service fee *
Convenience CC Fee
Total Cash/M.O. Amount
USD

Total CC Amount:

USD Description

Credit Card
First Name	Last Name
Credit Card Number	Security Code (CVC code)
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Comments/Notes
Customer Signature *

By signing the presented receipt, I've agreed to make the payment for the amount listed above. My signature also indicates I have read and understood all aspects and guidelines of my policy. I am aware that my policy expires at 12:01am (Midnight) the day the policy is scheduled to expire/cancel. I also understand my application for my auto insurance policy may use electronic signatures, and I acknowledge that I have been explained every clause where my signature or initial has been used. Full authorization has been given to my agent. I understand my vehicle is not covered until pictures and full documentation is submitted to my agent/company. Accident, tickets, claims, and/or major/minor violations, felonies, and misdemeanors have been disclosed to the agent. If inaccurate information is given, it may result in an increase on the total premium. Remco / Amco Insurance are not responsible for policies cancelled by your insurance company. I understand that Remco Insurance/ Amco Insurance are not responsible for any accidents, liabilities, or injuries that may occur while present in any Remco/ Amco Insurance office. I agree to be contacted via Text Message, Email, and/or Phone call from Remco/Amco Agent , or any affiliated company regarding my insurance policy. I also agree to receive Text Messages, Emails and or phone calls for Payment Reminders and Marketing advertising on new products and updates offered. I am aware Agency fees do apply in addition to your premium and any monies collected by REMCO / AMCO INSURANCE are NON-REFUNDABLE THAT ARE BROKEN DOWN ABOVE. I agree that these fees are consider to be fully earned by the the Agency at the time of the policy and will *NOT BE REFUNDABLE* upon cancellation. Agency fees may vary depending on the time it takes our agents to work on your policy. I was verbally informed of the statement above which relates that Effective 1/1/2014, the Texas Legislature passed SB 1567 that will impact the Limited & Named Driver Policy. "Warning: A NAMED DRIVER POLICY DOES NOT PROVIDE COVERAGE FOR INDIVIDUALS RESIDING IN THE INSURED'S HOUSEHOLD THAT ARE NOT NAMED ON THE POLICY" I acknowledge that my agent went through and explained all the products that we offer like car rental, homeowners, mobile home, renters/apartment, commercial auto/property, and several other products that we offer. I also acknowledge that roadside assistance is not automatically included on my policy and comes at an extra one time small fee. Arbitration. Any dispute directly or indirectly arising out of or related to customer's purchase of insurance shall be resolved by Confidential binding arbitration per the Texas Arbitration Act and the American Arbitration Association ("AAA") rules, but the arbitration does not have to be conducted through AAA if all parties agree. If the parties cannot agree on an arbitrator, a list of five AAA arbitrators will be obtain from AAA, and the arbitrator will be selected using alternate strikes with customer striking first. Cost of arbitration will be shared equally by the parties. Judgment on the award rendered by the arbitrator may be entered in a court having jurisdiction. "Confidential" means no party can discuss or disclose any information obtained or presented during the arbitration proceeding or the results of the proceeding except as required by law, the request or requirement of any judicial, legislative, administrative, or other governmental body. Clear
Should be Empty:

EMERGENCY CUSTOMER RECEIPT (When System Goes Down)

Office and Agent Information

Customer Details

Payment Details