Bill Pay

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1 PAYMENT DETAILS
2 REVIEW INFORMATION
First Name
Last Name
Account Address
Account Address Continued
City
Select Your State
Zip Code
Contact Phone Number
Policy Holder Name
Policy Number
Client of:

Account Information:

Policy Holder Name: [field 15]

Policy Number: [field 12]

Address: [field 5], [field 6], [field 7], [field 8], [field 9]
Phone Number: [field 10]

Email Address: [field 11]

Terms & Condition:


There's a 3% Surcharge for credit card payments. This secure service is offered by Stripe Payment Systems in agreement with your payment entity. All payments are processed immediately, and the payment date and time are equal to the time you complete this transaction and receive a confirmation. If your payment is unable to be processed, your payment liability will remain outstanding and you will be subject to any applicable penalties or interest. These obligations remain your sole responsibility. Stripe cannot issue refunds once your payment is processed and you receive a confirmation

Please make sure you enter and review all information carefully for accuracy prior to completing your transaction. By selecting the Accept Terms button on this page you are agreeing to these Terms and Conditions.
Payment Amount

Surcharge Amount: $[ ( field17 ) * 0.03 ]

Total Amount: $[ ( field17 * 0.03 ) + field17 ]

$ [ ( field17 * 0.03 ) + field17 ]
Billing Address
City
Select Your State
Zip

Do not press the back button after submitting the payment or you might be charged twice.

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