FORM-PAYMENT INFORMATION

Name: Louie (Lew) Thompson, Agent / Broker

Name of Agency: Brookridge Benefits, Inc.

Local: (229) 337-4727 (or) Toll Free: (800) 297-0817

Email: lewthompson3@gmail.com

Name * Required

Phone

Email * Required

Billing Address * Required

Type of Policy

Health

Medicare

Auto

Home

Business

Life

Banking Information

Bank Account Information

Type of Account: Checking / Savings

Name of Bank

Routing Number

Account Number

Credit / Debit Card

Name on Card

Card Number (16 Numbers)

Expiration Date (MM/YY)

CVV (Code on the Back of Card) 3-Digits

Zip Code Associated with this Card