Customer Payment By Check

	*Arizona Premium Finance Co.*
	....The Driving Force in Premium Finance 800-873-2732

Customer Payments by Check

CUSTOMERS ONLY - AGENTS DO NOT USE THIS PAGE

Pay one payment by check or set-up a monthly automatic payment from your checking account.
Payment requests received by 1:00PM Arizona time will be processed the next business day. Payment requests received after 1:00PM Arizona time, will be processed within 2 business days.

Customer Information

First Name
Last Name
APFC Account Number		Your 8 digit account number
Address
City, State, Zip		,
Home Telephone		212-555-6666
Work Telephone		212-555-6666
Email Address
Social Security Number		555-12-3456

Check Information - refer to picture of check above for help
Bank Name
Bank Routing Number
Checking Account #
Name on Checking Account
Checking Account Address
Checking Account City, State Zip		,

Payment Options - select one option

Debit my checking account One Time for the option selected below.
- there is a $10 fee for this service.

Set me up for Automatic Debit every month for the amount due
- there is a $5 per payment fee for this service.

Select either payment option described above:
Select Number of Payments to Pay: