SECURE ORDER FORM

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      By clicking this box   I understand that I will be charged $ 49 for the complete book of reputable car insurance companies.

      Organization Name:
      YOUR NAME:
      Address:
      City, State, Zip: ,
      Country:
      Telephone:
      Fax:
      Email:
      Your present URL: http://
      Car Insurance you have now:
      Type of Car:
      What type of Coverage do you want:
      Paying By Credit Card  
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      Paying by Check
      Name on Check:
      Address:
      City, State, Zip: ,
      Name of Bank:
      Address of Bank:
      City, State, Zip: ,
      9 Digit Routing # Bottom Left of check:
      Account #:
      Check#:
        
      Order the report on the Top insurance companies!
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      Electronic Signature:
        By clicking in this box I understand that this is a check transaction, I authorize A-Action Insurance Quotes to issue a check draft in the amount stated above.
      Checks will be made payable to A-Action Insurance Quotes
        By clicking this box I understand that due to any returned Check(s) "Drafts" because of NSF, Stop Payment (fraud), False information or any other act's deemed Intentional by the customer. Said customer may be assessed an additional $20.00 Fee per incident. By authorizing this order, customer agrees that A-Action Insurance Quotes can generate an electronic draft "check" for fee(s) that may be due without further notice.

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