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    ​Concierge Enrollment Form

    Credit Card Payment

    ​Please read the following information carefully. Check the box to indicate that you have read and understand the terms and conditions outlined.
    I authorize Insuragy, LLC to debit the annual payment or monthly payment due to Insuragy, LLC through the specified account each month on the anniversary date of the subscription indicated at enrollment. I understand that Insuragy, LLC  will withdraw only the amount due at the time of withdrawal. I also understand that any outstanding balance incurred before my enrollment will not be subject to automatic payment, and must be paid separately. I acknowledge that I am responsible for remitting payment for any payments not honored by my bank or other financial institution, plus any additional charges, to bring my account current.  Insuragy, LLC reserves the right to discontinue the service at any time for any reason. If my account falls behind in payments, after notice provided by Insuragy, LLC I authorize Insuragy, LLC to withdraw any amount necessary to bring my account current with the next regularly scheduled draft, in addition to my regularly scheduled payment. It is my responsibility to notify Insuragy, LLC of any changes made to my account information. Changes must be made at least five (5) business days prior to the next month's regularly scheduled draft. I understand that this authorization and the monthly automatic payments will remain in full force and effect until revoked by me, my financial institution, or Insuragy, LLC in such time and manner to allow a reasonable opportunity to act on it. By signing this authorization, I acknowledge that I am a signature authority on the account.