This is a Request to Make a Payment.

Your payment cannot be processed until all 3 steps below are completed. Completion of this form does not automatically bind coverage.

Step 1

Submit Your Payment Request by filling in this page and clicking the "Next"button.
(Unless the items with an asterisk (*) are completed, your payment request will be declined.)

 
Step 2

Your Payment Request is reviewed by the company you are paying.

 
Step 3 You Get an E-mail Notification telling you your payment request has been accepted or declined.

If your payment request is accepted, the date and time of acceptance will reflect the time of submission. This date and time will show on your payment submission acknowledgment.

IMPORTANT NOTE:  Your payment is not made until you receive an e-mail notification. You should receive this no later than the next business day after you submit your payment request.

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