Electronic Check Payment

Disclaimer: There is no charge to process your check payment. Once you process this payment, please void this check # from your registry

First Name *

Last Name *

ZIP / Postal Code *

E-Mail Address *

Check Number # (As it appears on your check) *

Company Name (As it appears on your check) *

Address (As it appears on your check) *

City, State and Zip (As it appears on your check) *

Name of your Banking Institution *

Amount of your Payment/Check *

Bank Routing Number *

Checking Account Number *

I Authorize Preferred American Insurance Services as signatory agent for my check number and amount listed above in United States Dollars. *

YES
NO
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Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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