Credit Card Authorization

You can now make your payment to eNational Insurance, DBA Jack Green Insurance, by using a your credit card on our Web Site. Simply fill out the form below and submit. If your payment is approved it will be applied to your account for payment on the insurance policy you specify.  If you have any questions or would prefer to pay by phone, please call us at 251-344-5393

Customer (Company) Name:
Account/Policy/Invoice Number:
(As it appears on your invoice)
Policy Description:
(i.e. Workman's Comp, Property, Homeowners)
Amount of the Insurance Payment:
Note: a 3% service fee will be added to the total.

Credit Card Information:
Credit Card Number:
Expire Date:
Month: (2 digits)
Year: (4 Digits)
Fraud Prevention:
Billing Zip Code
Security Code
Your Name:
By typing your name, you affirm that you are an authorized signer for this card.
Your Email Address:
Your Phone Number:
By submitting this form, I affirm that I am an authorized signer on this account, and that I Authorize eNational Insurance (DBA Jack Green Insurance) to automatically charge the specfied amount to this payment card, plus 3% for processing. For a total payment of .