Header
Cardholder Information*
Title*  
First Name*  
Last Name*  
Company
Billing Address*
Address 1*  
Address 2
City*  
 
 
Postal Code*    
Phone*  
(10 digit number, no dashes or brackets)
Fax
Email*    
Comments
Payment Information*
(This form will only accept payment for ONE policy per payment)
   
Policy Number*
(eg. 12345A01)
   
Amount*  
Credit Card Information*
   
Credit Card Type*  
Cardholder Name*  
Card Number*  
Security Code*  
Expiry Date*    

Press 'Place Order' button once only.


Bertie and Clinton Mutual Insurance Company
1789 Merrittville Hwy., R.R. #2
Welland, Ontario Canada L3B 5N5
Tel: (905) 892-0606 Toll Free: (800) 263-0494 Fax: (905) 892-0365
E-mail: mail@bertieandclinton.com
© Bertie and Clinton Mutual Insurance Company. All Rights Reserved.