BR Quote Form
By completing this secured form, you authorize American Ventures, Inc., D/B/A Advanced Insurance Services to facilitate in providing your checking information as indicated below.
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Name as shown on check
If you are making a payment for your company, please list the name of your company here.
Name of Authorized Signer
Contact Phone Number
Bank Routing Number
Checking Account Number
Amout to debit
Set up EFT for monthly payments with Finance Company
To set up auto deductions for an audit payment
To pay an audit in full
To set up EFT payments with insurance company
I authorize uploading payment from my checking to the insurance company
Advanced Insurance Services does not accept payments by check, this information is being accepted as a customer service facilitation only.
Notate any special instructions you want in this section.
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