Merit Payment Plan (New Contract Application)
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Insured Name
If Insured is a corporation or organized as, enter here. Or, enter individual name. This information is only for identification for new account on submission and may be generalized.
Insurance Agent Name (sending form)
First Name
Last Name
Email of Insurance Agent
agent@insurancebroker.ca
Upload Signed Merit Insurance Premium Finance Contract
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May be signed as Buyer, PAP and Continuous, for each applicable person
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Payment Method
Please Select
PAP
Credit or Debit Card
Coupon-Etransfer, OnlineBank Pay
Coupon- Broker Pay, Cheque, Cash, Other
Banking Information
For PAP
Bank Name or Bank Number
Example: RBC 003
Routing Number
Bank Account Number
Credit or Debit Card Information
Card Number
Expiry Date
MM/YY
CCV
3 digits
Upload Copy of Void Cheque or PAP Authorization
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Name on Card, if different than account name
Postal Code of customer
Customer Email
example@example.com
Customer Tel Number
-
Area Code
Phone Number
Upload Copy of Card, if you have it (both sides please)
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Coupon- Etransfer or Online Bank Payment
Please enter email that the customer will be sending Etransfer from, if known
Name of Bank for Online Bank Payments, if known
Coupon- Broker Pay, Cheques, Other
Please describe anticipated form of payment
Inception Payment/ Down Payment
Broker Collected Down Payment in Full
Merit to Collect Down Payment in Full
Credit or Debit Card applied for MeritPay Now Down Payment
Credit card applied for MeritPay Down Payment Deferral
Transfer Funds from Prior Account (in whole or part)
Merit to Collect Down Pay Plus Missed Payments
Customer sending Down Payment to Merit by Etransfer or other
Broker sending Down Payment to Merit (broker may retain it)
Merit to Collect specific amount as specified in Special Request or Notes to be Provided
Proposed Date for Withdrawal
-
Month
-
Day
Year
if none selected, it will be within 2 business days of date of receipt
Dec Page
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Upload terms and dec as applicable
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Special Request or Notes
256-bit Encryption Upload
Should be Empty: