Production Insurance

Film Emporium Production Insurance

Credit Card Authorization Form

All short-term insurance sales are non-cancellable.
All insurance sales are subject to a 3.5% credit card surcharge.

Please fill out the following form, print, attach a copy of your credit card (front and back) and fax to:

212/683.2740 or 888/229.6247-NY
323/464-7348- LA

Your Quote Number
Your Call Back Number

Cardholder's Name
Last Name
First Name

Billing Address (for credit card)
Address
Address 2
City
State
Zip
Country

I hereby authorize Film Emporium to debit my	AMEX VISA MasterCard
Account Number
Expiration Date
Three or four digit Security Code on the back of the card
For the purchase dated
In the amount of	$
Issuing Bank
Issuing Bank Phone #
Cardholder's signature	____________________________
Date

Please copy your credit card in the space provided below
Front of Card

Back of Card

Questions or comments? Call us at 212/683.2433 or 800/371.2555 (9am-6:00pm EST)
Los Angeles: 323 464 5144 or 866/464 5144 (9am -6pm PST)
or email us at insurance@filmemporium.com.
Thank you for your patronage. ©2007, Film Emporium.