Welcome to Input 1 Payments (powered by Input 1, LLC.)

If payment is for a new policy, please enter "New" in the Policy # field. For bank accounts in the name of a business enter the business name in first and last name fields.

First Name

Last Name

Address 1

Address 2

Country

City

State

Postal Code

E-mail

Phone

INSURED NAME

POLICY #

MEMO

Payment Amount

convenience fee

total payment amount

credit card type

credit card number

credit card expiration

card security code

I understand that submitting payment does not guarantee coverage until confirmed by the agency. Additionally, I understand that payment does not guarantee coverage in the event the policy has entered a cancellation status by the insurance company.

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METHOD:

CARD NUMBER:

EXPIRATION DATE:

PAYMENT AMOUNT:

CONVENIENCE FEE:

TOTAL PAYMENT AMOUNT:

I authorize a one-time payment in the amount of from the card information specified above on .

METHOD:

ACH

BANK ACCOUNT NUMBER:

ROUTING NUMBER:

PAYMENT AMOUNT:

CONVENIENCE FEE:

TOTAL PAYMENT AMOUNT:

I authorize a one-time ACH debit in the amount of from the bank account specified above on . I understand that this payment authorization may not be revoked after I click the “Authorize” button below.

METHOD (CAD):

ACH

BANK ACCOUNT NUMBER:

ROUTING NUMBER:

ACCOUNT TYPE:

PAYMENT AMOUNT:

CONVENIENCE FEE:

TOTAL PAYMENT AMOUNT:

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