USVI Public Records

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GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES 4008 Estate Diamond 2314 Kronprindsens Gade Lot 7-B Christiansted Charlotte Amalie V.I. 00802 V.I. 00820-4421 Tel: (340)774-4750 Tel: (340)773-1105 Fax: (340)774-9434 Fax: (340)773-8145 www.usvifinance.info/ DEPARTMENT OF FINANCE Office of the Government Insurance Fund Credit/Debit card Payment Authorization Form Insured’s Name (print name): ___________________________________________ Name on Credit/Debit card (print name): __________________________________ I, _________________, authorize The Government Insurance Fund to charge the following credit card to pay for Worker’s Compensation Insurance Premiums incurred on the named insured’s policy. I understand that these charges will be charged to the card listed below on the date authorized by my signature below, with the possibility that the card will not charged up to five days past the due date. I further understand that if this credit card is declined for any reason, I am responsible for paying the insurance premiums on or before the due date. I understand that I will be responsible for any late charges that accrue due to the denial of this credit card. I also release Government Insurance Fund/Government of the United States Virgin Islands from any liability associated with holding this information of file. Credit Card Type: __________________________________ Credit Card Number: ________________________________ Expiration Date: ____________________________________ __________________________ ____________________ Authorized Signature Date __________________________ ____________________ Authorized Signature Date