Payment Authorization Form
I hereby authorize WEBBER & ASSOCIATES, INC., a Georgia corporation, to initiate this one time withdrawal from my account indicated below as a one time electonic deduction.
If processed by bank draft, I understand that an authorized agent of Webber & Associates, Inc. will sign the bank draft as my agent for this transaction only.
This authorization is valid for this transaction only. No other bank drafts may be created without my/our direct written or verbal authorization.
submissions or payments made via this website do not constitute a
binding agreement to your policy or coverages. Changes and
payments to policies are not effective or binding until you, or any
party involved, receive official notice from either your insurance agent,
or your insurance company. If you have any questions, please feel free to
Per the terms of our
we will not resell your information to any third-party.