Payment Reporter
To report a payment or a credit received at brokerage
Insured Name, if individual, to identify account
First Name
Last Name
Insured Name, if Entity, to identify account
This may be legal corporate name or organized as
Insurance Agent Name, sending Payment Reporter
First Name
Last Name
Insurance Brokerage Name
Or Merit Broker Code
Sender Broker Email
agent@brokerinsurance.ca
Merit Account Number
Merit#, or Merit Tracker
Merit Payment Due
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
Example: Request suspend account action
Print
Secure Send
Should be Empty: