| Client Name as it appears on your BBIMI paperwork (may be different than the name on your checking account): |
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| Your Name: |
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Policy or Invoice Number
(Leave blank if unknown) |
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| This Payment Is For: |
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Which BBIMI team member
are you working with? |
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| I understand that submitting payment does not guarantee coverage until confirmed by the agency. Additionally, I understand that payment does not guarantee coverage in the event the policy has entered a cancellation status by the insurance company. |
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