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.)
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| Step 2 |
Your Payment Request is reviewed by the company you are paying.
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| 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.
