Credit Application for Charge Account

Insurance Company/Billing Details

Adjuster Name:

Company Name:

Address 1:

Address 2:

City:

Province:

Postal Code :

Email:

Telephone:

Fax:

Approximate Credit Required Per Month:

Client Name:

Claim #:

Address 1:

Address 2:

Telephone:

Please advise us of any instructions or restrictions on the account:

Charge account will be supplied with preprinted charge vouchers. A voucher must be given to the driver for each trip.
Account is billed by the first day of each month and is due upon receipt.
Any late account will be subject to a late charge of 3% per month.
In the event of lost or stolen vouchers, all charges incurred are the responsibility of your company until our office is notified.
A monthly service charge of 3% applies to all accounts.