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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.
If you are close to the Cancellation Date,
call our office to make the payment, instead of using this form.

Customer Information
First Name or Business Name  
Last Name or Business Owner 
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  
     
     
Payment Options - select one option
Debit my checking account One Time for the option selected below. 
- there is a $10 fee for this service, except in NY.

Set me up for Automatic Debit every month for the amount due
- there is a $5 per payment fee for this service, except in NY.
 
Select either payment option described above:

Select Number of Payments to Pay Now:

I hereby authorize Arizona Premium Finance Co. to submit an ACH transaction to my Bank based upon the information provided above.
 

If you want to pay the Down Payment on an Additional Premium, please call us at 602-992-9898

Be sure to check the "I'm not a robot" box below before pressing submit

Press the Submit Button ONLY ONCE