Payment Reporter
To report a payment or a credit received at brokerage
Insured Name, to identify account
This may be any name, legal corporate name or organized as
Merit Account Number
Merit#, or Merit Tracker
Insurance Brokerage Name
Or Merit Broker Code
Insurance Agent, or Customer Name or Representative Name Who Communicated Reporting Payment
Name of Person who Provided the Payment Information
Sender Agent at Broker Email
agent@brokerinsurance.ca
Merit Payment Due, if known
Payment Amount, or Adjusted Amount as applicable
Amount Received at Broker for Amount Due
Amount to be forwarded to Merit
Amount Received as a Credit on Insured's Account at Brokerage
Amount Advised Customer will make payment
Date Advised Customer Will Make Payment
-
Month
-
Day
Year
Date
Proposed Method of Payment
Etransfer
Bill Pay
Credit Card
PAP
Other
Special Request/ Notes Regarding Payment Reporting Information/ Notes
Example: Request suspend account action
Name of Merit Team Who is Sending this or was Communicated with for Payment Report
Print
Secure Send
Should be Empty: