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Payments Lab
Broker's Merit
Simple, Secure, Bank or Financial Institution Pay
*
Indicates required field
First Name, Last Name
*
First
Last
Policy Number/ Broker Name
*
Account Info: 3 Digit Bank Identifier
*
5 digit Transit Number
*
7 digit Account Number
*
Amount to be Paid
*
Check As May Apply
*
Re-occuring charge
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Payments Lab
Broker's Merit
