Knapp Insurance
1040 Partridge Pl Ste 2
Helena, MT 59602
(406) 442-1414
(866) 442-1414
(406) 442-3172 (fax)
office@knappins.com

Insurance Premium Payment Form

Your feedback matters!
Most of our clients submit small monthly payments and have complained about the $3.00 fee. We have decided that instead of a $3.00 fee, we will charge a 3% fee to any payment. This form will calculate that fee and total for you. We appreciate your feedback and we apologize for any inconvenience.

The information provided here must match the information with the credit card company.
Fields marked * are required.

First Name:

Last Name:

If commercial policy, company name:

Address:

City:

State:

Zip:

Your Phone:

() - *

Email Address:

Policy Number:

Credit/Debit Card Information

Method:

VISA Mastercard Discover
American Express

Card Number:

- - -
Please add your credit card in 4 digit increments.
(If American Express, last box will be 3 digits.)

Card Expiration Date:

CVV2 Number:

Payment Amount:

$ *

Processing Fee:

Total Amount Submitted:

Fields marked * are required.

Please enter your insurance company, due date
and any other information you may feel is relevant:*

*By clicking this box, you state that you have read and agree to the Terms & Conditions

Extended Validation Certificate

Online Payments

Date: 02/06/2012
Time: 04:44:02
Your IP address: 38.107.179.231