Assurance Systems
Secure Payment Form - eCheck

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Online Payment Summary:
Payment Date: 07/25/17
Payment Amount:
Service Description: AccuAgency (rating and management)
AgencyThrive (websites & web marketing)
Customer IP: 54.156.78.4 
           
Checking Account Information:      Click here to pay by Credit Card
Account Holder Name:
Bank Routing Number:
Bank Account Number:
Billing Information:
AccuAgency Account #:
Agency Name:
First Name:
Last Name:
Email Address (for receipt):
By clicking the 'Process Payment' button, you agree with the following terms and conditions: I authorize Assurance Systems, Inc., to debit the bank account or credit card indicated in this web form for the noted amount on today's date. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card or bank account, and that I will not dispute the payment with my Credit Card Company or Bank, so long as the transaction corresponds to the terms indicated in this web form.