eCheck Premium Payment This form is intended for payment of premiums by online check only. This option is more secure and is processed quicker than mailing a check. We do not accept credit card payments.Agency NameAgency Name for which this payment is being made (if applicable), Name of Organization or Person PayingName on CHECK (person/org paying). Carrier/Insurance Company* Policy Number* Total Payment Amount* EmailEmail address the receipt should be sent to. eCheck Bank Information Name on Account Bank Name Routing Number Account Number Account TypeCheckingSavings
