CREDIT CARD PAYMENT FORM
TRUCKERS OCCUPATIONAL ACCIDENT INSURANCE

Payment Information

First Name of Insured Driver:
Last Name of Insured Driver:


 

 

DayTime Phone:

 - -

   

Email:

Email verify:

Address of Insured:

 

City:

 

State:

    Zipcode: 

Select The Plan You Are Paying For
If you are not sure which plan you are paying for
refer to your billing invoice
or
call us at 708-478-7499
Occupational Accident Insurance ONLY
Plan 1 - $146 ($143 Monthly for Occ/Acc + $3 Monthly for NITACA dues)
Plan 1A - $170 ($167 Monthly for Occ/Acc + $3 Monthly for NITACA dues)
Plan 2 - $136 ($133 Monthly for Occ/Acc + $3 Monthly for NITACA dues)
Plan 3 - $125 ($122 Monthly for Occ/Acc + $3 Monthly for NITACA dues)

Occupational Accident Insurance and Passenger Accident Insurance
Plan 1PA - $156 ($143 Monthly for Occ/Acc + $10 Monthly for Pass/Acc + $3 Monthly for NITACA dues)
Plan 1APA - $180 ($167 Monthly for Occ/Acc + $10 Monthly for Pass/Acc + $3 Monthly for NITACA dues)
Plan 2PA - $146 ($133 Monthly for Occ/Acc + $10 Monthly for Pass/Acc + $3 Monthly for NITACA dues)
Plan 3PA - $135 ($122 Monthly for Occ/Acc + $10 Monthly for Pass/Acc + $3 Monthly for NITACA dues)

 
A $5.00 Processing Fee will be added to the total amount due.

     
Credit Card Holder's Name 
        
(Payment instructions will appear on confirmation screen after online enrollment has been successfully submitted.)



Driver Signature:

Date:

Signature - Type Your Name Here
 

 

After you submit this renewal form, you will taken to a secure page to continue the online credit card payment process

 

Clear Form Fields

 

Be assured that all information you provide here is secure. Please reference our Privacy Policy for more information on our commitment to using information provided here strictly in conjuction with obtaining Occupational Accident Insurance.

Pallay Insurance Agency, Inc. Home
 
 
 
 
 
 
 
 
 

Contact Us

Pallay Insurance Agency
P.O. Box 727
Mokena, IL 60448

Phone:
708.478.7499


Truckers Occupational Accident Insurance Online Request Form

 PALLAY INSURANCE AGENCY, INC.