intlbondmarine.epaypolicy.com
Open in
urlscan Pro
2606:4700::6812:a20
Public Scan
Submitted URL: http://sales.epay3.com/t/107654/c/608c099b-2eee-449a-a7a6-287a62258293/NB2HI4DTHIXS62LOORWGE33OMRWWC4TJNZSS4ZLQMF4XA33M...
Effective URL: https://intlbondmarine.epaypolicy.com/
Submission: On April 11 via api from NL — Scanned from NL
Effective URL: https://intlbondmarine.epaypolicy.com/
Submission: On April 11 via api from NL — Scanned from NL
Form analysis 2 forms found in the DOM
POST /
<form action="/" enctype="multipart/form-data" id="payment-form" method="post" sessionid="" novalidate="novalidate"><input data-val="true" data-val-required="The MakeFieldsReadonly field is required." id="MakeFieldsReadonly" name="MakeFieldsReadonly"
type="hidden" value="False">
<div class="row">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label for="payer">Payer</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<span class="field-validation-valid" data-valmsg-for="Payer" data-valmsg-replace="true"></span>
<input class="form-control" data-bind="value: payer" data-val="true" data-val-maxlength="The Payer has a maximum length of 150 characters." data-val-maxlength-max="150" data-val-required="The Payer field is required." id="Payer"
name="Payer" placeholder="Payer" required="" type="text" value="">
</div>
</div>
</div>
<div class="col-sm-12">
<div class="form-group email">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label for="email">Email Address</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<span class="field-validation-valid" data-valmsg-for="EmailAddress" data-valmsg-replace="true"></span>
<input class="form-control" data-bind="value: emailAddress" data-val="true" data-val-email="The Email Address is not properly formatted"
data-val-maxlength="The field Email Address must be a string or array type with a maximum length of '150'." data-val-maxlength-max="150" data-val-required="The Email Address field is required." id="EmailAddress" name="EmailAddress"
placeholder="Email Address" required="" type="text" value="">
</div>
</div>
</div>
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label>Invoice # (s)</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<span class="field-validation-error transaction-attribute-regex-error-msg" style="display:none" data-valmsg-for="TransactionAttribute4209" data-valmsg-replace="true"></span>
<span class="field-validation-error" style="display:none" data-valmsg-for="TransactionAttribute4209" data-valmsg-replace="true">The Invoice # (s) field is required.</span>
<input name="TransactionAttribute4209" class="form-control full " data-bind="textInput: TransactionAttribute4209" data-toggle="popover" data-trigger="manual focus" id="TransactionAttribute4209" onblur="validateCustomAttribute(event)"
pattern="(.*?)" placeholder="If paying multiple, you may use the attachments option below" required="" type="text" value="">
</div>
</div>
</div>
</div>
<div class="row" style="display: none;" data-bind="visible: model.invoices().some(i => i.FinanceDownPayment() > 0)">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label>Premium Finance Agreement</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<span id="show-pfa-text" class="pfa-supporting-text" data-bind="visible: !isAgreementValid(), style: {color: showInvalidAgreementMessage() ? 'red' : '' }"><i class="fas fa-exclamation-circle pfa-invalid-exclamation"></i> Please go through
the <b>Premium Finance Agreement</b> before going ahead.</span>
<div>
<button type="button" class="btn btn-primary pfa-btn pfa-btn-not-consented" id="show-pfa" data-bind="click: showAgreement, class: pfaBtnStatus">
<span>View Premium Finance Agreement & Sign</span>
<span data-bind="visible: agreementButtonCheckDisplay()" id="pfa-check-display" style="display: none;">
<i class="fas fa-check-circle pfa-valid-check"></i>
</span>
</button>
<span data-bind="visible: premiumFinanceAgreementLoading()" id="loading-pfa" style="display: none;">
<i class="fas fa-spinner fa-spin"></i> <label class="pfa-supporting-text">Loading Premium Finance Agreement...</label>
</span>
</div>
<div class="col-lg-5 col-md-5 col-sm-5 left pfa-supporting-text text-danger" data-bind="visible: premiumFinanceAgreementErrored()" style="display: none;">
<span>Something has gone wrong when trying to retrieve your premium finance agreement. Please click the button to retry or pay your financed invoice in full.</span>
</div>
</div>
</div>
</div>
</div>
<div class="modal fade" id="termsAndConditionsModalDialog" tabindex="-1" role="dialog" aria-hidden="true" style="display: none;">
<div class="modal-dialog max-size-modal">
<div class="modal-content">
<div class="modal-header">
<button type="button" class="close" data-dismiss="modal" ,="" aria-hidden="true">×</button>
<h4 class="model-title">Terms & Conditions</h4>
</div>
<div class="modal-body">
<span class="" data-bind="text: autoPayTermsAndConditions()"></span>
</div>
<div class="modal-footer">
<button type="button" class="btn btn-default" data-dismiss="modal">OK</button>
</div>
</div>
</div>
</div>
<div class="row" style="display: none;" data-bind="visible: showAgreementFinancialBreakdown()">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label>Financial Breakdown</label>
<div class="breakdown-payment-financing-logo">
<div>
<img height="85%" width="85%" data-bind="attr:{src: premiumFinanceCompanyLogoUri, alt: premiumFinanceAgreementCompanyName}" id="pfc-logo" src="" alt="">
</div> Financial Plan Provided by <span data-bind="text: premiumFinanceAgreementCompanyName"></span>
</div>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<div class="breakdown-wrapper">
<table>
<thead class="breakdown-header">
<tr>
<th class="breakdown-th">Down Payment Amount</th>
<th class="breakdown-th">Installment Amount</th>
<th class="breakdown-th">Number of Payments</th>
<th class="breakdown-th">Next Installment Due Date</th>
</tr>
</thead>
<tbody>
<tr>
<td class="breakdown-td" data-cell="down payment amount"><span data-bind="text: formatAmount(totalDownPaymentAmount(), 'USD')">$0.00</span></td>
<td class="breakdown-td" data-cell="installment amount">
<div>
<div>
<span class="breakdown-installment-fee" data-bind="text: formatAmount(installmentAmount(), 'USD')">$0.00</span>
</div>
<span class="breakdown-installment-autopay-fee" data-bind="visible: premiumFinanceAgreementAutoPay()" style="display: none;">+ additional fee</span>
</div>
</td>
<td class="breakdown-td" data-cell="number of payments"><span data-bind="text: financeNumberOfPayments() + ' (' + financePaymentFrequency() + ')'">0 ()</span></td>
<td class="breakdown-td" data-cell="next installment due date"><span data-bind="text: nextInstallmentDueDate()"></span></td>
</tr>
</tbody>
</table>
</div>
<div class="breakdown-payment-message" data-bind="visible: premiumFinanceAgreementAutoPay()" style="display: none;">
<span data-bind="text: '*Estimated additional autopay fee for ACH of ' + formatAmount(autoPayAchFee(), 'USD') + ' or Credit Card of ' + formatAmount(autoPayCreditCardFee(), 'USD') + ' assessed by ePayPolicy.'">*Estimated additional
autopay fee for ACH of $0.00 or Credit Card of $0.00 assessed by ePayPolicy.</span>
</div>
<div class="breakdown-payment-message checkbox" data-bind="visible: allowFinanceAutoPay()">
<input type="checkbox" name="EnableFinancingAutoPay" id="EnableFinancingAutoPay" data-bind="checked: premiumFinanceAgreementAutoPay, value: premiumFinanceAgreementAutoPay" value="false">
<label for="EnableFinancingAutoPay"><span id="pfcName" data-bind="text: autoPayDisclaimerText()"></span></label>
</div>
<div class="terms-and-conditions" data-bind="visible: showAutoPayTermsAndConditionsLink()" style="display: none;"><a href="#" data-bind="click: showTermsAndConditionsModal">Terms & Conditions</a></div>
</div>
</div>
</div>
</div>
<div class="payment-amount row">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label for="amount">Amount</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<span class="field-validation-valid" data-valmsg-for="Amount" data-valmsg-replace="true"></span>
<input class="form-control" data-bind="numeric, value: amount" data-val="true" data-val-number="The field Amount must be a number." data-val-range="The Amount must be greater than 0." data-val-range-max="10000000" data-val-range-min="0.01"
data-val-required="The Amount field is required." id="Amount" name="Amount" placeholder="Amount (e.g. 123.45)" required="" type="text" value="">
</div>
</div>
</div>
</div>
<div class="row payment-type">
<div class="col-sm-12">
<div class="form-group clearfix">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label for="payment-type">Payment Type</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right clearfix">
<div class="large-device">
<label for="paymentType" class="payment-ui-card clearfix">
<input type="radio" class="form-control payment-radio" name="paymentType" data-bind="click: function() {setPaymentType('Ach'); return true;}, value: 'Ach', checked: paymentMethod" value="Ach">
<div class="payment-ui-card-wrapper">
<div class="ui-card-header ">
<img src="/images/echeck-icon.png" class="img-responsive" alt="credit-card-icon">
<h3 class="text-center">ACH</h3>
</div>
<div class="ui-card-details">
<div class="ui-card-row">
<span class="row-label">Amount</span>
<span class="info" data-bind="text: formatAmount(amount(), 'USD')">$0.00</span>
</div>
<div class="ui-card-row fees">
<span class="row-label">Fee</span>
<span class="info" data-bind="text: amount() > 0 ? formatAmount(payerAchFee(), 'USD') : 'Enter Amount'">Enter Amount</span>
</div>
<div class="ui-card-row totals">
<span class="row-label" data-bind="text: enableScheduledPayments() ? 'Each Payment' : 'Total'">Total</span>
<span class="info" data-bind="text: formatAmount(amount() > 0 ? achTotal() : 0, 'USD')">$0.00</span>
</div>
</div>
<div class="radio-button">
<span></span>
</div>
</div>
</label>
<label for="paymentType" class="payment-ui-card clearfix">
<input type="radio" class="form-control payment-radio" name="paymentType" data-bind="click: function() {setPaymentType('CreditCard'); return true;}, value: 'CreditCard', checked: paymentMethod" value="CreditCard">
<div class="payment-ui-card-wrapper">
<div class="ui-card-header ">
<img src="/images/credit-card-icon.png" class="img-responsive" alt="credit-card-icon">
<h3 class="text-center">Credit Card</h3>
</div>
<div class="ui-card-details">
<div class="ui-card-row">
<span class="row-label">Amount</span>
<span class="info" data-bind="text: formatAmount(amount(), 'USD')">$0.00</span>
</div>
<div class="ui-card-row fees">
<span class="row-label"> Fee </span>
<span class="info" data-bind="text: amount() > 0 ? formatAmount(payerCreditCardFee(), 'USD') : 'Enter Amount'">Enter Amount</span>
</div>
<div class="ui-card-row totals">
<span class="row-label" data-bind="text: enableScheduledPayments() ? 'Each Payment' : 'Total'">Total</span>
<span class="info" data-bind="text: formatAmount(amount() > 0 ? creditCardTotal() : 0, 'USD')">$0.00</span>
</div>
</div>
<div class="radio-button">
<span></span>
</div>
</div>
</label>
</div>
<div class="small-device">
<div class="options-row clearfix">
<label for="mobilePaymentType" class="payment-ui-card clearfix">
<input type="radio" class="form-control payment-radio" name="mobilePaymentType" data-bind="click: function() {setPaymentType('Ach'); return true;}, value: 'Ach', checked: paymentMethod" value="Ach">
<div class="radio-button">
<span></span>
</div>
<div class="ui-card-header">
<img src="/images/echeck-icon.png" class="img-responsive" alt="ach-icon">
<h3 class="text-center">ACH</h3>
</div>
</label>
<label for="mobilePaymentType" class="payment-ui-card clearfix">
<input type="radio" class="form-control payment-radio" name="mobilePaymentType" data-bind="click: function() {setPaymentType('CreditCard'); return true;}, value: 'CreditCard', checked: paymentMethod" value="CreditCard">
<div class="radio-button">
<span></span>
</div>
<div class="ui-card-header">
<img src="/images/credit-card-icon.png" class="img-responsive" alt="credit-card-icon">
<h3 class="text-center">Credit Card</h3>
</div>
</label>
</div>
<div class="payment-ui-card-wrapper left-tab" data-bind="visible: paymentMethod() == 'CreditCard'" style="display: none;">
<div class="ui-card-details">
<div class="ui-card-row">
<span class="row-label">Amount</span>
<span class="info" data-bind="text: formatAmount(amount(), 'USD')">$0.00</span>
</div>
<div class="ui-card-row fees">
<span class="row-label">Fee</span>
<span class="info" data-bind="text: amount() > 0 ? formatAmount(payerCreditCardFee(), 'USD') : 'Enter Amount'">Enter Amount</span>
</div>
<div class="ui-card-row totals">
<span class="row-label" data-bind="text: enableScheduledPayments() ? 'Each Payment' : 'Total'">Total</span>
<span class="info" data-bind="text: formatAmount(amount() > 0 ? creditCardTotal() : 0, 'USD')">$0.00</span>
</div>
</div>
</div>
<div class="payment-ui-card-wrapper right-tab" data-bind="visible: paymentMethod() == 'Ach'">
<div class="ui-card-details">
<div class="ui-card-row">
<span class="row-label">Amount</span>
<span class="info" data-bind="text: formatAmount(amount(), 'USD')">$0.00</span>
</div>
<div class="ui-card-row fees">
<span class="row-label"> Fee </span>
<span class="info" data-bind="text: amount() > 0 ? formatAmount(payerAchFee(), 'USD') : 'Enter Amount'">Enter Amount</span>
</div>
<div class="ui-card-row totals">
<span class="row-label" data-bind="text: enableScheduledPayments() ? 'Each Payment' : 'Total'">Total</span>
<span class="info" data-bind="text: formatAmount(amount() > 0 ? achTotal() : 0, 'USD')">$0.00</span>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="payment-info row">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label for="payment-info">Payment Information</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right" data-bind="visible: paymentMethod() == 'CreditCard'" style="display: none;">
<div class="form-group">
<div data-bind="visible: tokenPublicId() == 'newCreditCard' || creditCardTokenCount() == 0 || true" style="">
<div class="row">
<div class="col-lg-12">
<span class="field-validation-valid" data-valmsg-for="CardAccountHolder" data-valmsg-replace="true"></span>
<input autocomplete="off" class="form-control" data-val="true" data-val-maxlength="The Name on Card has a maximum length of 40 characters." data-val-maxlength-max="40" id="CardAccountHolder" name="CardAccountHolder"
placeholder="Name on Card" type="text" value="">
</div>
</div>
<div class="row">
<div class="col-lg-12">
<span class="field-validation-valid" data-valmsg-for="CardNumber" data-valmsg-replace="true"></span>
<span class="ccInput">
<input autocomplete="off" class="form-control" data-bind="textInput: cardNumber" data-val="true" data-val-maxlength="The Card Number has a maximum length of 16 characters." data-val-maxlength-max="16" id="CardNumber"
maxlength="16" name="CardNumber" placeholder="Credit Card Number" type="text" value="">
<!-- ko if: cardType() == 'DISCOVER' || cardType() == undefined --><i class="fab fa-2x fa-cc-discover"></i><!-- /ko -->
<!-- ko if: cardType() == 'AMEX' || cardType() == undefined --><i class="fab fa-2x fa-cc-amex"></i><!-- /ko -->
<!-- ko if: cardType() == 'MASTERCARD' || cardType() == undefined --><i class="fab fa-2x fa-cc-mastercard"></i><!-- /ko -->
<!-- ko if: cardType() == 'VISA' || cardType() == undefined --><i class="fab fa-2x fa-cc-visa"></i><!-- /ko -->
</span>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-6">
<input autocomplete="off" class="form-control" data-val="true" data-val-number="The field Month must be a number." id="Month" name="Month" placeholder="Month (MM)" type="text" value="">
</div>
<div class="col-lg-6 col-md-6 col-sm-6">
<input autocomplete="off" class="form-control" data-val="true" data-val-number="The field Year must be a number." id="Year" name="Year" placeholder="Year (YYYY)" type="text" value="">
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-6">
<input autocomplete="off" class="form-control" data-val="true" data-val-maxlength="The CVC has a maximum length of 4 characters." data-val-maxlength-max="4" data-val-regex="The CVC can only contain numbers."
data-val-regex-pattern="^\d{3,4}$" id="CVC" name="CVC" placeholder="CVC" type="text" value="">
</div>
<div class="col-lg-6 col-md-6 col-sm-6">
<input autocomplete="off" class="form-control" id="PostalCode" maxlength="6" name="PostalCode" placeholder="Postal Code" type="text" value="">
</div>
</div>
<div class="row" data-bind="if: paymentMethod() != 'Ach'"></div>
</div>
</div>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right" data-bind="visible: paymentMethod() == 'Ach'">
<div>
<div class="tab-pane" id="2a">
<div class="form-group">
<div data-bind="visible: tokenPublicId() == 'newAch' || achTokenCount() == 0 || true" style="">
<div class="row">
<div class="col-lg-12">
<span class="field-validation-valid" data-valmsg-for="BankAccountHolder" data-valmsg-replace="true"></span>
<input autocomplete="off" class="form-control" data-val="true" data-val-maxlength="The Account Holder has a maximum length of 40 characters." data-val-maxlength-max="40" id="BankAccountHolder" name="BankAccountHolder"
placeholder="Bank Account Holder" type="text" value="" required="required">
</div>
</div>
<div class="row">
<div class="col-lg-12">
<span class="field-validation-valid" data-valmsg-for="RoutingNumber" data-valmsg-replace="true"></span>
<input autocomplete="off" class="form-control" data-original-title="Routing Number" data-toggle="popover" data-trigger="manual focus" data-val="true" data-val-maxlength="The Routing Number has a maximum length of 9 characters."
data-val-maxlength-max="9" id="RoutingNumber" name="RoutingNumber" placeholder="Routing Number" type="text" value="" required="required">
</div>
</div>
<div class="row">
<div class="col-lg-12">
<span class="field-validation-valid" data-valmsg-for="AccountNumber" data-valmsg-replace="true"></span>
<input autocomplete="off" class="form-control" data-original-title="Account Number" data-toggle="popover" data-trigger="manual focus" data-val="true" data-val-maxlength="The Account Number has a maximum length of 17 characters."
data-val-maxlength-max="17" data-val-minlength="The Account Number has a minimum length of 3 characters." data-val-minlength-min="3" data-val-regex="The account number can contain only digits." data-val-regex-pattern="\d+"
id="AccountNumber" name="AccountNumber" placeholder="Account Number" type="text" value="" required="required">
</div>
</div>
<div class="row">
<div class="col-lg-12">
<input autocomplete="off" class="form-control" data-original-title="Confirm Account Number" data-toggle="popover" data-trigger="manual focus" data-val="true" id="ConfirmAccountNumber" name="ConfirmAccountNumber"
placeholder="Confirm Account Number" type="text" value="" required="required">
</div>
</div>
<div class="row" data-bind="if: paymentMethod() == 'Ach'">
<div class="col-md-12">
<div class="checkbox" data-bind="click: ShowSignInPopup">
<input autocomplete="off" class="form-control" id="SavePaymentOption" name="SavePaymentOption" type="checkbox" value="true"><input name="SavePaymentOption" type="hidden" value="false">
<label for="SavePaymentOption">Save my bank account for future use</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row" id="attachments">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label>Attachments</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<table cellpadding="10" role="presentation" class="table">
<tbody class="files" data-bind="foreach: attachments"></tbody>
</table>
<div class="fileupload-buttonbar">
<div class="left">
<div class="btn add-btn fileinput-button">
<i class="fas fa-plus-circle" aria-hidden="true"></i>
<label id="files-label" for="files">Add files...</label>
<input id="files" type="file" name="files[]" data-url="/Attachments/Upload" accept=".pdf,.csv,.png,.jpg,.jpeg,.doc,.docx,.zip,.xlsx" multiple="">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row notes clearfix">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label>Notes</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<fieldset>
<span class="field-validation-valid" data-valmsg-for="Comments" data-valmsg-replace="true"></span>
<textarea class="notes-textarea" cols="20" id="Comments" name="Comments" placeholder="This box is for your reference only.
Any information entered here will be displayed on your receipt but will not be viewed or responded to by IB&M." rows="5"></textarea>
</fieldset>
</div>
</div>
</div>
</div>
<!--ko if:model.shouldAutopayEnable-->
<div class="row autopay" style="display:none" data-bind="visible: autoPaySubscriptionId() == null && hasAccount()">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left">
<label>AutoPay</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<label class="switch">
<input class="form-control" data-val="true" data-val-required="The EnableAutoPay field is required." id="autopay-enable" name="EnableAutoPay" tabindex="-1" type="checkbox" value="true"><input name="EnableAutoPay" type="hidden"
value="false">
<span class="slider round"> </span>
</label>
<label for="autopay-enable"> Enable AutoPay for future invoices. <span class="learn-more"><a href="#" data-bind="click: openAutopayModal">Learn more</a></span>
</label>
</div>
</div>
</div>
</div>
<!--/ko-->
<div class="row payment-confirmation">
<div class="col-sm-12">
<div class="form-group">
<div class="col-lg-offset-1 col-md-offset-1 col-sm-offset-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left"></div>
<div class="col-lg-9 col-md-9 col-sm-9 right">
<div class="checkbox" data-bind="visible: isAgreementValid()" style="display: none;">
<input type="checkbox" name="FinanceConnectDisclaimerAccepted" id="FinanceConnectDisclaimerAccepted" data-bind="checked: financeConnectDisclaimerAccepted">
<label for="FinanceConnectDisclaimerAccepted">By checking this box, I am agreeing to ePayPolicy's Finance Connect <a href="https://epaypolicy.com/terms-FC/" target="_blank">Provider Notice</a>.</label>
</div>
<p class="agreement">
<label id="standard-disclaimer" class="" for="confirm-disclaimer">
<label id="confirm-disclaimer-label" for="confirm-disclaimer"> By clicking "Send", I authorize International Bond & Marine Brokerage LTD to debit my account. <span data-bind="visible: payerFee() > 0" style=""> I understand that
<span data-bind="visible: enableScheduledPayments() == false">this payment</span>
<span data-bind="visible: enableScheduledPayments" style="display: none;">each of the <span data-bind="text: numberOfPayments(), visible: numberOfPayments() > 0" style="display: none;"></span> payments</span> includes a <span
data-bind="text: formatAmount(payerFee(), 'USD')">$4.00</span> fee assessed by <a href="http://epaypolicy.com" target="_blank">ePayPolicy</a>. </span>
</label>
</label>
</p>
<p>
</p>
<div class="g-recaptcha" data-sitekey="6LeDxZwpAAAAAM8huWYzvoKay-WM4B-1JzvM9s_A">
<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA" width="304" height="78" role="presentation" name="a-n52er42y4p7x" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox allow-storage-access-by-user-activation"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6LeDxZwpAAAAAM8huWYzvoKay-WM4B-1JzvM9s_A&co=aHR0cHM6Ly9pbnRsYm9uZG1hcmluZS5lcGF5cG9saWN5LmNvbTo0NDM.&hl=nl&v=rz4DvU-cY2JYCwHSTck0_qm-&size=normal&cb=5cb4zao9k90h"></iframe>
</div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
<input type="hidden" class="hiddenRecaptcha required" name="hiddenRecaptcha" id="hiddenRecaptcha">
<br>
<p></p>
<input type="submit" name="submitButton" class="btn btn-success" value="Send" id="Submit" data-bind="css: { 'inactive' : !confirmDisclaimer() }, click: submitForm">
<input type="hidden" id="PaymentMethod" name="PaymentMethod" data-bind="value: paymentMethod" value="Ach">
<input type="hidden" id="EnableScheduledPayments" name="EnableScheduledPayments" data-bind="value: enableScheduledPayments" value="false">
<input type="hidden" id="ScheduledPaymentsEndOption" name="ScheduledPaymentsEndOption" data-bind="value: scheduledPaymentsEndOption" value="Never">
<input type="hidden" id="TokenPublicId" name="TokenPublicId" data-bind="value: submitTokenPublicId">
<input type="hidden" id="DuplicateTransactionReceiptUrl" name="DuplicateTransactionReceiptUrl" data-bind="value: duplicateTransactionReceiptUrl">
<input type="hidden" name="QuoteNumber" data-bind="value: premiumFinanceAgreementQuoteNumber">
<input type="hidden" name="PremiumFinanceAgreementCompanyName" data-bind="value: premiumFinanceAgreementCompanyName">
<input type="hidden" name="PremiumFinanceAgreementConsent" data-bind="value: premiumFinanceAgreementConsent" value="false">
<input type="hidden" name="PremiumFinanceAgreementName" data-bind="value: premiumFinanceAgreementName">
<input type="hidden" name="PremiumFinanceAgreementPhone" data-bind="value: premiumFinanceAgreementPhone">
<input type="hidden" name="PremiumFinanceAgreementEmail" data-bind="value: premiumFinanceAgreementEmail">
<input id="PreAuthorizationCode" name="PreAuthorizationCode" type="hidden" value="">
<input data-val="true" data-val-date="The field PreAuthorizationDate must be a date." id="PreAuthorizationDate" name="PreAuthorizationDate" type="hidden" value="">
<input data-val="true" data-val-number="The field ClientNotificationId must be a number." id="ClientNotificationId" name="ClientNotificationId" type="hidden" value="">
<input name="__RequestVerificationToken" type="hidden" value="ldj__Yvo9WNEHEP8cNMb3siHjNonRmbfeuqCz_Ggwnw0Mz1WgU194CejMjv3-a3fczSNu8usHoWfsJGX1xIMUwUecPM1">
<input type="hidden" name="attachments" id="attachments" data-bind="value: fileModels" value="[]">
</div>
</div>
</div>
</div>
<div id="bankAccountNumberPopup" style="display: none">
<div><img src="/images/account-number.png"></div>
</div>
<div id="bankRoutingNumberPopup" style="display: none">
<div><img src="/images/routing-number.png"></div>
</div>
</form>#
<form id="pfa-form" action="#" novalidate="novalidate">
<div>
<div class="row" style="padding-top: 5px; padding-bottom: 5px;">
<div class="col-sm-12">
<input type="checkbox" id="premiumFinanceAgreementConsent" name="premiumFinanceAgreementConsent" style="vertical-align: top;" data-bind="checked: modalPremiumFinanceAgreementConsent, value: modalPremiumFinanceAgreementConsent" required=""
value="false">
<label for="premiumFinanceAgreementConsent" style="display: inline; font-weight: 100; vertical-align: -2px;">By checking this box, I assert that I have reviewed and agree to all the terms set forth in the premium finance agreement.</label>
</div>
<div class="col-sm-12">
<div class="col-lg-9 col-md-9 col-sm-9 left" style="padding-bottom: 1px;">
<span style="font-weight: bold;">Digitally sign the Premium Finance Agreement</span>
</div>
</div>
<div class="col-sm-12" style="line-height: 1;">
<div class="form-group">
<div class="col-lg-1 col-md-1 col-sm-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left" style="padding-bottom: 1px;">
<label for="premiumFinanceAgreementName">Name</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right" style="margin-bottom: 5px;">
<input type="text" class="form-control" name="premiumFinanceAgreementName" id="premiumFinanceAgreementName" data-bind="value: modalPremiumFinanceAgreementName" required="">
</div>
</div>
</div>
<div class="col-sm-12" style="line-height: 1;">
<div class="form-group">
<div class="col-lg-1 col-md-1 col-sm-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left" style="padding-bottom: 1px;">
<label for="premiumFinanceAgreementPhone">Phone Number</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right" style="margin-bottom: 5px;">
<input type="tel" class="form-control" name="premiumFinanceAgreementPhone" id="premiumFinanceAgreementPhone" inputmode="tel" placeholder="555-555-5555" data-bind="value: modalPremiumFinanceAgreementPhone" required="">
</div>
</div>
</div>
<div class="col-sm-12" style="line-height: 1;">
<div class="form-group">
<div class="col-lg-1 col-md-1 col-sm-1 col-lg-2 col-md-2 col-sm-2 col-xs-12 left" style="padding-bottom: 1px;">
<label for="premiumFinanceAgreementEmail">Email Address</label>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right" style="margin-bottom: 5px;">
<input type="email" class="form-control" name="premiumFinanceAgreementEmail" id="premiumFinanceAgreementEmail" inputmode="email" data-bind="value: modalPremiumFinanceAgreementEmail" required="">
</div>
</div>
</div>
</div>
</div>
</form>Text Content
* Sign In * Sign Up * Sign In * Sign Up ×Close ×Close ×Close A duplicate transaction was recently submitted. To submit this payment anyways, please re-enter the payment information. If there are questions or concerns, please reach out to your insurance provider. MAKE A PAYMENT Please enter your payment information below Payer Email Address Invoice # (s) The Invoice # (s) field is required. Premium Finance Agreement Please go through the Premium Finance Agreement before going ahead. View Premium Finance Agreement & Sign Loading Premium Finance Agreement... Something has gone wrong when trying to retrieve your premium finance agreement. Please click the button to retry or pay your financed invoice in full. × TERMS & CONDITIONS OK Financial Breakdown Financial Plan Provided by Down Payment Amount Installment Amount Number of Payments Next Installment Due Date $0.00 $0.00 + additional fee 0 () *Estimated additional autopay fee for ACH of $0.00 or Credit Card of $0.00 assessed by ePayPolicy. Terms & Conditions Amount Payment Type ACH Amount $0.00 Fee Enter Amount Total $0.00 CREDIT CARD Amount $0.00 Fee Enter Amount Total $0.00 ACH CREDIT CARD Amount $0.00 Fee Enter Amount Total $0.00 Amount $0.00 Fee Enter Amount Total $0.00 Payment Information Save my bank account for future use Attachments Add files... Notes AutoPay Enable AutoPay for future invoices. Learn more By checking this box, I am agreeing to ePayPolicy's Finance Connect Provider Notice. By clicking "Send", I authorize International Bond & Marine Brokerage LTD to debit my account. I understand that this payment each of the payments includes a $4.00 fee assessed by ePayPolicy. × PREMIUM FINANCE AGREEMENT By checking this box, I assert that I have reviewed and agree to all the terms set forth in the premium finance agreement. Digitally sign the Premium Finance Agreement Name Phone Number Email Address Download Agreement Cancel Agree × Cancel Confirm × OK