Agency Bill Payment Request Use this form to have a custom payment link sent to your customer. This should be used for agency bill items only. Agent Name*SelectAlan BourassaAshley LopezCarole MontelloDaniel DyeDarren DyeDavid ZepedaDebbie AndersonGary WelteJoe UtleyJohn CerioKen GarnerMarleen HayashiMiti PulaRon DyeI'm not sureWho is your insured?* What is your client's Email* This is where we will send the payment link for payment and/or receipt of paymentDo you already have your client's CC or EFT info for payment?* Yes, CC (add 3.5% total) Yes, EFT (add $1 total) No, please send them a link to pay on their own Please provide your customer's CC info*Name on CCCC#ExDateCVV CodeBilling Zip Please provide your customer's EFT info*Name on AccountRouting #Account # What is the General Agency Name?* What is the policy type?* General Liability Property Package/BOP Commercial Auto Workers Comp Umbrella Other This will appear in the memo section of the payment link invoiceIf the premium is financed, what is the name of the premium finance company? How will the customer pay?* EFT (add $1 to your total) CC (add 3.5% to your total) Total payment amount* Please include $1 for EFT payment or 3.5% for CC payment methodDoes your payment amount include a Broker Fee?* Yes No What is the Broker Fee amount being added to the downpayment?