The completion of the form below and your $300 payment constitute your continued acceptance of our "Advertising Agreement" and will continue your companies listing(s) on InsBuyer.com for an additional 12 months. If changes need to be made to your listing please contact by phone to discuss details.

Remember, the form below must be submitted and payment made before the 1st of the month to receive the $300 renewal rate.

Company Name:
Contact:
Address:
City: State: Zip:
Local Phone # Toll Free #
FAX # E-mail:
Company Web Site URL:

Payment Information
(Visa, Mastercard, American Express & Discover, Check)
Name as it appears on your card*
Billing address for your card*(where you receive your statement)
Card Number* (spaces and dashes may be used)
Expiration Date*        Amount Billed*
     $300

Right Click and print this page for your own records.
After your payment is received and processed a Paid Invoice will be mailed to your credit card billing address for your records.

For personal service contact:
Diversified Insurance Services
16321 FM 344 W., Suite 6
Bullard, TX 75757
(903) 825-7758    Attn.: Dennis Rogers