Allen Financial Insurance Group

Insured Policy Bind Request
Capitol Insurance Company


Please complete the form below to submit a policy bind request.
You can also attach and transmit underwriting documents and pay on-line.
A representative from our office will contact you shortly after receiving the bind request.
Policies should not be considered bound until you recieve a confirmation from our office.
Please call 800-874-9191 or 602-992-1570 for assistance.

 Policyholder Information




1.  Annual Premium Payment by Check
2.  Annual Premium Payment by Credit Card

3.  3 Pay EFT Installment Plan
  • 40% is due on or before effective date
  • 30%, plus a $10.00 installment fee is due the third month after the effective date
  • 30%, plus a $10.00 installment fee is due the sixth month after the effective date
4.  6 Pay EFT Installment Plan
  • 25% is due on or before the effective date
  • 15%, plus a $10.00 installment fee, is due the first month after the effective date
  • 15%, plus a $10.00 installment fee, is due the second month after the effective date
  • 15%, plus a $10.00 installment fee, is due the third month after the effective date
  • 15%, plus a $10.00 installment fee, is due the fourth month after the effective date
  • 15%, plus a $10.00 installment fee, is due the fifth month after the effective date 
5.   Flex Pay Direct Bill
Capitol Indemnity Admitted policies only.  $750 minimum premium.  Minimum down payment of 20% of the total premium, plus 100% of all applicable surcharges or taxes. The insured is required to make a minimum 20% down payment plus fees but the number of remaining payments is flexible.

EFT Installment option requires fully executed EFT authorizion form completed by Insured.






For Immediate Assistance Call Toll Free 1-800-874-9191 



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