Credit Card Payment Available - Print, fill in and mail or fax this form.

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Paying Your Bill with Credit Card or E-Check

Credit Card and E-Checks Payment are available. There are two ways you can send it to us:

Fill out this form, print it and fax it to us at 518-762-7870
Fill out this form, print and mail it to: Fulmont Mutual Insurance Company, P.O. Box 487, Johnstown, NY 12095-0487 or E-mail: info@fulmontmutual.com

Name:	___________________________________________________
Company:	___________________________________________________
Street:	___________________________________________________
State/Prov.:	___________________________________________________
Zip Code:	____________________
Daytime Telephone:	___________________________________________________
Fax:	___________________________________________________
E-Mail:	___________________________________________________
Total Payment:	$_________________
Policy #:	___________________________________________________
Payment Method:	(Please Check One)
	VISA	E-Check	Bank Name:_________________ ABA#_________________ ACCT#________________
	MasterCard
Credit Card #:	___________________________________________________
CVV#: (What is my CVV code?)	_________
Expiration Date:	Month___________Year_________
Yes, I have double checked the entries that I have made, and I hereby authorize the total amount entered above to be charged to the credit card number or my bank account that I have entered.
Signature:	___________________________________________________
Date:	___________________________________________________

For further information regarding our policies, send e-mail to
info@fulmontmutual.com, or write to us at:
Fulmont Mutual Insurance Company
P.O. Box 487, Johnstown, NY 12095-0487