Web Check Authorization

You can now make your payment to eNational Insurance, DBA Jack Green Insurance, by using a WEB authorized check. Simply fill out the form below and submit. If your check is approved it will be applied to you 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 $4.95 service fee will be added to the total.

Checking Account Information:
Bank Name:
Routing Number:
Account Number:
Name on the Account:
Your Name:
By typing your name, you affirm that you are an authorized signer for this account.
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 debit the specfied amount from this checking account, plus $4.95 for processing.