PIA - PAYMENT INFORMATION REQUEST FORM

Business Name*

Type of Policy

Business Contact Name:*

First NameLast Name

Email*

example@example.com

Cell Phone Number*

Please enter a valid phone number.

Payment Type:*

Name as shown on Card:*

First NameMiddle InitialLast Name

Billing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Enter payment amount (before credit card processing fees)*

Credit Card Processing fee calculation

Total payment with processing fee*

USD

Credit Card

Please Note: Credit Card transactions are processed through a third-party vendor which assesses a non-refundable processing fee of 2.9% + .30 per transaction, if you use this form. Payment by phone is 3.5% + .30. For eCheck, the fee is 1% up to max of $15 and there may be up to a 5-day wait until the payment has cleared your bank and posted with PIA, Inc.

Enter Check Payment Amount*

Note: Check processing fee of 1% (max $15) will be added to payment total.

Total check amount to be processed (including 1% up to $15 max fee)

Bank Name*

Routing Number*

Account Number*

Bank Authorization*

I authorize a one-time payment for the above amount.

Disclosure Statement & Acknowledgment (you must acknowledge all by checking EACH box)*

Compensation will be paid to the Agent by the insurer(s) selling the insurance contract or by another third party in the form of commissions, based on the insurance contract the producer sells. The insurance purchaser may obtain information about compensation expected to be received upon request.In addition, we are authorized to charge an Agency fee, rewrite fees, postage, and certain services that are necessary to place or maintain your insurance. Please refer to your insurance agreement and/or invoice.

Signature*

Date

Hour MinutesAM/PM Option