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"Insurance For Every Horse Related Need"
Mortality, Major Medical & Surgical  * Personal Horse Owners Liability  * Commercial Equine Liability   * Boarding, Breeding,  Training, Race  * Care, Custody & Control  * Equestrian Schools  * Riding Instructors  * Saddle Animals For Hire  * Trail Rides  * Leasing  * Sales  * Pony Rides  * Petting Zoos 
 Hay, Sleigh or Carriage Rides  * Horse Clubs & Associations  * Horse Shows, Events, Clinics  * Equine Assisted Therapy  * Therapeutic Riding  * Trail & Endurance Rides  * Equine Camp  * Rodeo & Stock Contractors  * Guides & Outfitters  * Dude & Guest Ranches  * Horse Hauling / Transport  * Farrier Liability & Equine Service  * Non Profit Organization  * Farm & Ranch  * Horse Trailers & More
Entering your information  below authorizes us to use the  information to generate a bank draft (Check or Credit Card)  for the total amount entered. This authorization is for this transaction only. Further, you certify there are adequate funds to cover the stated amount, and that you have the authority to tender payment from said account. Also, you understand this transaction is between you and the Payee named on the account . 

To enter your information, just place your cursor in a field and start typing.
All Fields Are Required
 Name on Policy  
I,                                                                             hereby authorize Jackie Wade Equine

 Insurance Agent to charge my Bank Account in the amount of 
Please note that $2.95 will be added to the amount for payment processing fee.
Type of Account:        Checking Account     Saving Account
Account #
Account Routing #
Bank Name #
Checking/Saving Account Billing Address
Street:
City:
State:
Zip Code:
As the account holder, I hereby authorize the above charge(s)

Account Holder Signature 


Date:
Your completion of this authorization form helps us to protect you, our valued customers, from fraud. All information entered on this form will be kept strictly confidential by Jackie Wade Equine Insurance Agent.
All returned checks will be charged a $35.00 return fee and your policy will be
Flat Cancelled immediately. or will not be binded.
Need to use a Credit Card. All information is confidential and is not shared with anyone.

Card Number

Expiration Month / Year

CVV Code

Name On Card

Billing Zip Code

Amount 

Please note that 3% will be added to the amount for payment processing fee.
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