Modification Request

Modification Request

By Insured Customer using MeritPay for payments
Existing Customer Name (for identification)

First NameLast Name
Customer Email
example@example.com
Merit Account Number or Merit Tracker
Change Payment DateUrgent Payment DeferralUpdate with new Banking InformationReceive Coupons by MailCancel Insurance and payment planPay in FullMake a Claim (contact your insurance broker)Change Payment MethodAsk for Special assistance, accommodation, accessScheduling call, video conference or in-person meetingDeliver a ComplimentMake a ComplaintPassword to Access MeritPay account onlineChange Address on FileAdd or Change Telephone NumberAdd or Change Email on FileAdd or Change Name on File
Bank Name
Routing Number
Account Number
Add Telephone Number
Please enter a valid phone number.
Add Email
example@example.com
Change Your Acct Address To:

Street Address

Street Address Line 2

CityProvince

Postal Code
From Method: To Method:
Change Name or Spelling of Name on Account (or add an additional name)

First NameLast Name
On or off
Proposed Modified Payment Date
File Upload

Cancelof
Voice Message to send Merit a secure private audio message
use your mobile device to scan a document and upload
Provide Detailed Information for Request
Transmit Signature for application as requested

Clear
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Should be Empty: