I , hereby authorize Everyone Insurance ,
to duplicate the attached, or otherwise provided check, in bank draft form.
This authorization is valid for this transaction only.

The transaction amount will be for exactly $
This authorization is valid for [monthly | daily | weekly]
debits to my account by use of check draft.

This is an open authorization to allow debits to my account in check draft form for balance due on my account or future orders.

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 binding agreement and I will receive a copy of each check draft in my statement when the item has cleared.

    
Authorized Accountholder Signature              Date

TAPE YOUR CHECK HERE

Then Fax your order to:
(281) 817 5900

Everyone Insurance
6201 Bonhomme Road # 180 N Houston Texas 77036
Phone: (713) 974 7860 Fax: (281) 817 5900
Website Address: www.txsinsurance.com Email: syed@txsinsurance.com

I understand this is a legal binding agreement between

, and, Everyone Insurance , 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, Everyone Insurance 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.

         
Authorized Accountholder Signature              Date