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

*Initialing below acknowledges that you understand that submitting payment does not guarantee coverage until confirmed by Southwest Aviation Insurance Group.

*PLEASE INITIAL BELOW

NAME INSURED / POLICY NAME

INVOICE #

FAA N# / CUSTOMER #

E-mail

First Name

Phone

Last Name

Address 1

Address 2

MEMO:

City

State

Postal Code

Country

Bank Transfer

Payment Amount

convenience fee

total payment amount

credit card type

credit card number

credit card expiration

card security code

bank name

bank routing number

bank account number

bank account type

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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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