State Farm Enrollment Form – Monthly Payments

PIFPAC Mission Statement:

PIFPAC sets the playing field: PIFPAC defeats bad politicians who want to pick your pocket and raise costs for consumers and, instead, elects good legislative leaders to office.

PIFPAC members shape the future of our industry: By engaging in grassroots lobbying and providing professional lobbyists with the political clout they need to fight on your behalf in the Sacramento political arena, PIFPAC members shape the future of the business of insurance in California.
Membership levels
Monthly
- Diamond: $200
- Platinum: $100
- Gold: $75
- Silver: $50
- Bronze: $30
Total
$0.00
Please complete the following information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Sales Territory*
- I wish to contribute to PIFPAC utilizing EFT (electronic fund transfer).
Name on the account
Financial Institution
City
Routing # off your check, if available
Account #
Signature authorization
Date
- I wish to contribute to PIFPAC utilizing Credit Card.
Credit Card

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name