Note: All fields on this form must be completed in order for us to process your payment. 
Use the information from the check that you are paying with, AS IT APPEARS ON THE CHECK!

Business Name:

Address: 

City:,  State:
	CA
	AZ
	  ZIP Code:

Business Phone Number: (Please include area code) 

eMail Address: 

Enter the information as it appears on your check.

Bank Name:

Bank Addess: 

Bank City:, Bank State:
	CA
	AZ
	  Bank Zip Code 

Bank Phone: (if known - include area code please)

Now using the following lower portion of a personal check as an example, 
enter the information that appears at the bottom of your check. (See Sample Below)

Bank Routing or "Transit" Number:

Your Account Number:

Check Number:

Check Amount of your Payment:

Please read carefully:

Before you submit this request, please complete the next two lines confirming your request to have

Insurance Guys Insurance Services, Inc. issue your check to the bank for the above amount.

By giving your name and date, you are agreeing to the bank check payment you are about to submit.

I agree to the above amount for payment toward my insurance premium or fees.

Your Name: 

Today's Date: / /  (EX: 01/01/2006)

After you press the "Submit" button and receive the "Thank You" message.

You may choose to continue to any page on our site.