Formulaire - Transmission des informations de carte de crédit NID 488 EN Transmission of credit card information Required fields* Client, member or identification number * The identification number can be found on your invoice and/or the certificate. The member number is the one of your professional association. Payment * Yearly Monthly Insured family name * Insured first name * Email Address * Email confirmation * Name of the card holder as it appears * Card number (no space) * Card type * - Select -VisaMastercard Expiration * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year201720182019202020212022202320242025202620272028202920302031203220332034 CVV/CVC * The CVV/CVC code are located in the back of your credit card just beside the signature area and is always represented by the last three digit number. Notes Authorization * I/We hereby authorize Sogemec Assurances Inc. to make a wilhdrawal from my/our account at each renewal for the annual payment of premiums or, as the case may be, for the monthly payment of premiums on or about the first business day of each month in which insurance premiums are due. This authorization may be terminated by elther Sogemec Assurances Inc. or by me through wrltten notice. Sogemec Assurances inc. will terminale coverage or change the method of payment to another qualifying method should a withdrawal be refused for any reason and the financial institution shall in no way be held liable should such an event occur.