Payment Submission

What is the total that you wish to pay?*

Transaction Fee 3.5%

Total

Price: $0.00

What name is your insurance policy under?*

What type of policy are you paying for?*

PAYMENT INFORMATION:

Name*

First Last

Email*

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BILLING ADDRESS INFORMATION:*

Street Address City State / Province / Region ZIP / Postal Code Country

I, Arash, understand and agree to pay the additional 3.5% for processing fees.*

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Card Number Expiration Date Security Code Cardholder Name

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