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paulininsurance.appliedpay.com Open in urlscan Pro
2606:4700:4400::6812:2a90  Public Scan

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URL: https://paulininsurance.appliedpay.com/flow/hppv2
Submission: On December 09 via manual from US — Scanned from DE

Form analysis 2 forms found in the DOM

<form>
  <div class="flex-container">Select a pay by option and enter the required information below to proceed with your payment</div>
  <div class="flex-container mt-100">
    <div class="AccountInformationForm_payBy__dxN7+">Pay By</div>
    <div>
      <div class="RadioGroup_module_group__d1743cad">
        <div class="Radio_module_radio__db71d4ea"><input id="payBy-INVOICE" name="payBy" type="radio" class="Radio_module_input__db71d4ea" value="INVOICE"><label for="payBy-INVOICE">Invoice</label></div>
        <div class="Radio_module_radio__db71d4ea"><input id="payBy-AMOUNT" name="payBy" type="radio" class="Radio_module_input__db71d4ea" value="AMOUNT"><label for="payBy-AMOUNT">Amount</label></div>
      </div>
    </div>
  </div>
  <div class="flex-container mt-100 AccountInformationForm_flexNoWrap__agonu">
    <div class="AccountInformationForm_flexGrowOne__-RPkp">
      <div>
        <div data-label="true" class="Label_module_label__5243be76"><label for="firstName" class="required">First Name<div class="Label_module_requiredIcon__5243be76">
              <div class="Icon_module_wrapper__584d5c36" data-icon="RequiredIndicatorIcon"><svg height="12" width="12" class="Icon_module_icon__584d5c36 RequiredIndicatorIcon_module_fill__34e68815" viewBox="0 0 12 12" fill="none"
                  xmlns="http://www.w3.org/2000/svg">
                  <path fill-rule="evenodd" clip-rule="evenodd"
                    d="M6.89508 2.2L6.5696 5.30835L9.69422 4.42141L9.93834 6.1546L7.01714 6.41499L8.91307 8.94561L7.33448 9.8L5.95932 7.07409L4.73063 9.79186L3.08694 8.94561L4.9666 6.41499L2.06168 6.14646L2.33834 4.42141L5.406 5.30835L5.08052 2.2H6.89508Z">
                  </path>
                </svg></div>
            </div></label></div>
        <div class="TextField_module_wrapper__dc5c4681 undefined" style="width: 100%;">
          <div class="TextField_module_innerWrapper__dc5c4681"><input id="firstName" role="input" autocomplete="off" class="TextField_module_input__dc5c4681" name="firstName" spellcheck="false" type="text" tabindex="0" value=""
              style="text-align: left;"></div>
        </div>
      </div>
    </div>
    <div class="AccountInformationForm_flexGrowOne__-RPkp">
      <div>
        <div data-label="true" class="Label_module_label__5243be76"><label for="lastName" class="required">Last Name<div class="Label_module_requiredIcon__5243be76">
              <div class="Icon_module_wrapper__584d5c36" data-icon="RequiredIndicatorIcon"><svg height="12" width="12" class="Icon_module_icon__584d5c36 RequiredIndicatorIcon_module_fill__34e68815" viewBox="0 0 12 12" fill="none"
                  xmlns="http://www.w3.org/2000/svg">
                  <path fill-rule="evenodd" clip-rule="evenodd"
                    d="M6.89508 2.2L6.5696 5.30835L9.69422 4.42141L9.93834 6.1546L7.01714 6.41499L8.91307 8.94561L7.33448 9.8L5.95932 7.07409L4.73063 9.79186L3.08694 8.94561L4.9666 6.41499L2.06168 6.14646L2.33834 4.42141L5.406 5.30835L5.08052 2.2H6.89508Z">
                  </path>
                </svg></div>
            </div></label></div>
        <div class="TextField_module_wrapper__dc5c4681 undefined" style="width: 100%;">
          <div class="TextField_module_innerWrapper__dc5c4681"><input id="lastName" role="input" autocomplete="off" class="TextField_module_input__dc5c4681" name="lastName" spellcheck="false" type="text" tabindex="0" value=""
              style="text-align: left;"></div>
        </div>
      </div>
    </div>
    <div class="AccountInformationForm_flexGrowOne__-RPkp">
      <div>
        <div data-label="true" class="Label_module_label__5243be76"><label for="userEmail" class="required">Email Address<div class="Label_module_requiredIcon__5243be76">
              <div class="Icon_module_wrapper__584d5c36" data-icon="RequiredIndicatorIcon"><svg height="12" width="12" class="Icon_module_icon__584d5c36 RequiredIndicatorIcon_module_fill__34e68815" viewBox="0 0 12 12" fill="none"
                  xmlns="http://www.w3.org/2000/svg">
                  <path fill-rule="evenodd" clip-rule="evenodd"
                    d="M6.89508 2.2L6.5696 5.30835L9.69422 4.42141L9.93834 6.1546L7.01714 6.41499L8.91307 8.94561L7.33448 9.8L5.95932 7.07409L4.73063 9.79186L3.08694 8.94561L4.9666 6.41499L2.06168 6.14646L2.33834 4.42141L5.406 5.30835L5.08052 2.2H6.89508Z">
                  </path>
                </svg></div>
            </div></label></div>
        <div class="TextField_module_wrapper__dc5c4681 undefined" style="width: 100%;">
          <div class="TextField_module_innerWrapper__dc5c4681"><input id="userEmail" role="input" autocomplete="off" class="TextField_module_input__dc5c4681" name="userEmail" spellcheck="false" type="text" tabindex="0" value=""
              style="text-align: left;"></div>
        </div>
      </div>
    </div>
  </div>
  <div class="flex-container mt-150 AccountInformationForm_flexNoWrap__agonu">
    <div class="AccountInformationForm_flexNoGrowBasis30__mASo+">
      <div>
        <div data-label="true" class="Label_module_label__5243be76"><label for="businessName" class="">Business Name</label></div>
        <div class="TextField_module_wrapper__dc5c4681 undefined" style="width: 100%;">
          <div class="TextField_module_innerWrapper__dc5c4681"><input id="businessName" role="input" autocomplete="off" class="TextField_module_input__dc5c4681" name="businessName" spellcheck="false" type="text" tabindex="0" value=""
              style="text-align: left;"></div>
        </div>
      </div>
    </div>
    <div class="AccountInformationForm_flexNoGrowBasis30__mASo+">
      <div data-test="accountCode">
        <div data-label="true" class="Label_module_label__5243be76"><label for="accountCode" class="required">Account Number<div class="Label_module_requiredIcon__5243be76">
              <div class="Icon_module_wrapper__584d5c36" data-icon="RequiredIndicatorIcon"><svg height="12" width="12" class="Icon_module_icon__584d5c36 RequiredIndicatorIcon_module_fill__34e68815" viewBox="0 0 12 12" fill="none"
                  xmlns="http://www.w3.org/2000/svg">
                  <path fill-rule="evenodd" clip-rule="evenodd"
                    d="M6.89508 2.2L6.5696 5.30835L9.69422 4.42141L9.93834 6.1546L7.01714 6.41499L8.91307 8.94561L7.33448 9.8L5.95932 7.07409L4.73063 9.79186L3.08694 8.94561L4.9666 6.41499L2.06168 6.14646L2.33834 4.42141L5.406 5.30835L5.08052 2.2H6.89508Z">
                  </path>
                </svg></div>
            </div></label>
          <div class="Label_module_icon__5243be76"><span data-test="tooltip-testid" class="Tooltip_module_target__dadfb561">
              <div class="Icon_module_wrapper__584d5c36" data-icon="ICircleIcon"><svg height="16" width="16" class="Icon_module_icon__584d5c36 ICircleIcon_module_fill__86a21ef7" viewBox="0 0 16 16" fill="none" xmlns="http://www.w3.org/2000/svg">
                  <path fill-rule="evenodd" clip-rule="evenodd" d="M8 4C8.55228 4 9 4.44549 9 4.99502V5.00498C9 5.55451 8.55228 6 8 6C7.44772 6 7 5.55451 7 5.00498V4.99502C7 4.44549 7.44772 4 8 4Z"></path>
                  <path fill-rule="evenodd" clip-rule="evenodd"
                    d="M8 13.5C11.0376 13.5 13.5 11.0376 13.5 8C13.5 4.96243 11.0376 2.5 8 2.5C4.96243 2.5 2.5 4.96243 2.5 8C2.5 11.0376 4.96243 13.5 8 13.5ZM8 15C11.866 15 15 11.866 15 8C15 4.13401 11.866 1 8 1C4.13401 1 1 4.13401 1 8C1 11.866 4.13401 15 8 15Z">
                  </path>
                  <path fill-rule="evenodd" clip-rule="evenodd" d="M8 7.5C8.55228 7.5 9 7.94772 9 8.5V10.8C9 11.3523 8.55228 11.8 8 11.8C7.44772 11.8 7 11.3523 7 10.8V8.5C7 7.94772 7.44772 7.5 8 7.5Z"></path>
                </svg></div>
            </span></div>
        </div>
        <div class="TextField_module_wrapper__dc5c4681 undefined" style="width: 100%;">
          <div class="TextField_module_innerWrapper__dc5c4681"><input id="accountCode" role="input" autocomplete="off" class="TextField_module_input__dc5c4681" name="accountCode" spellcheck="false" type="text" tabindex="0" value=""
              style="text-align: left;"></div>
        </div>
      </div>
    </div>
    <div class="AccountInformationForm_flexNoGrowBasis15__1wKxv">
      <div>
        <div data-label="true" class="Label_module_label__5243be76"><label for="invoiceNumber" class="required">Invoice Number<div class="Label_module_requiredIcon__5243be76">
              <div class="Icon_module_wrapper__584d5c36" data-icon="RequiredIndicatorIcon"><svg height="12" width="12" class="Icon_module_icon__584d5c36 RequiredIndicatorIcon_module_fill__34e68815" viewBox="0 0 12 12" fill="none"
                  xmlns="http://www.w3.org/2000/svg">
                  <path fill-rule="evenodd" clip-rule="evenodd"
                    d="M6.89508 2.2L6.5696 5.30835L9.69422 4.42141L9.93834 6.1546L7.01714 6.41499L8.91307 8.94561L7.33448 9.8L5.95932 7.07409L4.73063 9.79186L3.08694 8.94561L4.9666 6.41499L2.06168 6.14646L2.33834 4.42141L5.406 5.30835L5.08052 2.2H6.89508Z">
                  </path>
                </svg></div>
            </div></label></div>
        <div class="TextField_module_wrapper__dc5c4681 undefined" style="width: 100%;">
          <div class="TextField_module_innerWrapper__dc5c4681"><input id="invoiceNumber" role="input" autocomplete="off" class="TextField_module_input__dc5c4681" name="invoiceNumber" spellcheck="false" type="text" tabindex="0" value=""
              style="text-align: left;"></div>
        </div>
      </div>
    </div>
    <div class="AccountInformationForm_flexNoGrowBasis15__1wKxv">
      <div>
        <div data-label="true" class="Label_module_label__5243be76"><label for="postalCode" class="required">Postal Code<div class="Label_module_requiredIcon__5243be76">
              <div class="Icon_module_wrapper__584d5c36" data-icon="RequiredIndicatorIcon"><svg height="12" width="12" class="Icon_module_icon__584d5c36 RequiredIndicatorIcon_module_fill__34e68815" viewBox="0 0 12 12" fill="none"
                  xmlns="http://www.w3.org/2000/svg">
                  <path fill-rule="evenodd" clip-rule="evenodd"
                    d="M6.89508 2.2L6.5696 5.30835L9.69422 4.42141L9.93834 6.1546L7.01714 6.41499L8.91307 8.94561L7.33448 9.8L5.95932 7.07409L4.73063 9.79186L3.08694 8.94561L4.9666 6.41499L2.06168 6.14646L2.33834 4.42141L5.406 5.30835L5.08052 2.2H6.89508Z">
                  </path>
                </svg></div>
            </div></label></div>
        <div class="TextField_module_wrapper__dc5c4681 undefined" style="width: 100%;">
          <div class="TextField_module_innerWrapper__dc5c4681"><input id="postalCode" role="input" autocomplete="off" class="TextField_module_input__dc5c4681" name="postalCode" spellcheck="false" type="text" tabindex="0" value=""
              style="text-align: left;"></div>
        </div>
      </div>
    </div>
  </div>
  <div class="flex-container flex-align-end mt-150"><button type="submit" class="Button_module_button__6ffcfea1 Button_module_primary__6ffcfea1 brandPrimaryButton">
      <div class="Button_module_buttonContents__6ffcfea1">Continue to Policy Information</div>
    </button></div>
</form>

<form>
  <div data-grid-row="true" class="Row_module_row__4ff93fa8">
    <div data-grid-col="true" class="Col_module_col__3625c59c mb-150 Col_module_xs12__3625c59c">Select the invoices you would like to pay.</div>
  </div>
  <div class="flex-container">
    <div data-grid-row="true" class="Row_module_row__4ff93fa8">
      <div data-grid-col="true" class="Col_module_col__3625c59c Col_module_xs12__3625c59c">
        <div class="DataGrid_module_container__50d312c3" data-test="invoiceDataGridTest" style="min-width: 350px; max-height: 800px;">
          <div data-test="invoiceDataGridTest-column-grid" class="DataGrid_module_grid__50d312c3" style="grid-template-columns: 42px 43px minmax(auto, auto) minmax(auto, auto) minmax(auto, auto);">
            <div data-test="column" data-column="0" class="DataGridColumn_module_column__efee7438 DataGridColumn_module_isClickable__efee7438" tabindex="-1" data-ads-component-type="dataGridColumnHeader">
              <div class="DataGridColumn_module_text__efee7438">
                <div class="Icon_module_wrapper__584d5c36 DataGridToggleIcon_module_toggleIcon__66ec7534" data-icon="ChevronIcon"><svg height="16" width="16" viewBox="0 0 16 16" fill="none"
                    class="Icon_module_icon__584d5c36 ChevronIcon_module_overrideStroke__ea09e4c8" xmlns="http://www.w3.org/2000/svg">
                    <path fill-rule="evenodd" clip-rule="evenodd" d="M2.293 5.293a1 1 0 0 1 1.414 0L8 9.586l4.293-4.293a1 1 0 1 1 1.414 1.414l-5 5a1 1 0 0 1-1.414 0l-5-5a1 1 0 0 1 0-1.414z" class="Icon_module_fill__584d5c36"></path>
                  </svg></div>
              </div>
            </div>
            <div data-test="column" data-column="1" class="DataGridColumn_module_column__efee7438" tabindex="-1" data-ads-component-type="dataGridColumnHeader">
              <div class="DataGridColumn_module_text__efee7438"><span data-test="tooltip-testid" class="Tooltip_module_target__dadfb561"><span data-test="tooltip-testid" class="Tooltip_module_target__dadfb561">
                    <div data-test="invoiceDataGridTest-check-all" class="Checkbox_module_checkbox__144e338b Checkbox_module_reverse__144e338b DataGrid_module_checkboxHeader__50d312c3"><input id="cd22144f-e5f5-4b54-b709-fe069347d17b" name="check-all"
                        type="checkbox" class="Checkbox_module_input__144e338b"><label class="" for="cd22144f-e5f5-4b54-b709-fe069347d17b"></label></div>
                  </span></span></div>
            </div>
            <div data-test="column" data-column="2" class="DataGridColumn_module_column__efee7438 DataGridColumn_module_isClickable__efee7438" tabindex="-1" data-ads-component-type="dataGridColumnHeader">
              <div class="DataGridColumn_module_text__efee7438">Invoice Number</div>
              <div class="DataGridColumn_module_sortIcon__efee7438">
                <div class="Icon_module_wrapper__584d5c36" data-icon="SortArrowIcon"><svg width="16" height="16" class="Icon_module_icon__584d5c36" viewBox="0 0 16 16" fill="none" xmlns="http://www.w3.org/2000/svg" style="transform: rotate(180deg);">
                    <path d="M12 9L8 13M8 13L4 9M8 13V3" class="Icon_module_stroke__584d5c36" stroke="#444750" stroke-width="1.25" stroke-linecap="round" stroke-linejoin="round"></path>
                  </svg></div>
              </div>
            </div>
            <div data-test="column" data-column="3" class="DataGridColumn_module_column__efee7438 DataGridColumn_module_isClickable__efee7438" tabindex="-1" data-ads-component-type="dataGridColumnHeader">
              <div class="DataGridColumn_module_text__efee7438">Due Date</div>
            </div>
            <div data-test="column" data-column="4" class="DataGridColumn_module_column__efee7438 DataGridColumn_module_isLast__efee7438 DataGridColumn_module_isClickable__efee7438" tabindex="-1" data-ads-component-type="dataGridColumnHeader">
              <div class="DataGridColumn_module_text__efee7438">Amount Due</div>
            </div>
            <div style="height: 0px; grid-column: 1 / -1;"></div>
            <div style="height: 0px; grid-column: 1 / -1;"></div>
            <div class="DataGrid_module_noResults__50d312c3">No items found</div>
          </div>
          <div data-test="invoiceDataGridTest-footer" class="DataGrid_module_footer__50d312c3 py-50 pr-100 pl-100">
            <div class="DataGrid_module_alignRight__50d312c3" data-test="total-rows">0 Items</div>
            <div class="DataGrid_module_alignLeft__50d312c3" data-test="total-rows-checked">0 Items Checked</div>
          </div>
        </div>
      </div>
    </div>
  </div>
  <div class="flex-container flex-align-end mt-150"><button type="button" class="Button_module_button__6ffcfea1 Button_module_tertiary__6ffcfea1">
      <div class="Button_module_buttonContents__6ffcfea1">Back</div>
    </button><button type="submit" data-test="continue-to-payment" class="Button_module_button__6ffcfea1 Button_module_primary__6ffcfea1 brandPrimaryButton" disabled="">
      <div class="Button_module_buttonContents__6ffcfea1">Continue to Payment</div>
    </button></div>
</form>

Text Content

Log In
Create an Account
Back to Make a Payment


MANAGE YOUR ACCOUNT





MAKE A PAYMENT

Enter information below to make a payment.


1. ACCOUNT INFORMATION

Select a pay by option and enter the required information below to proceed with
your payment
Pay By
Invoice
Amount
First Name


Last Name


Email Address


Business Name

Account Number



Invoice Number


Postal Code


Continue to Policy Information


2. POLICY INFORMATION

Select the invoices you would like to pay.
Invoice Number

Due Date
Amount Due


No items found
0 Items
0 Items Checked
Back
Continue to Payment


3. PAYMENT METHOD

Choose your payment method

Use Payment Method on File
Back

If a Convenience Fee is shown above, our systems platform provider, Applied
Systems, Inc., will apply a Non-Refundable fee or charge to the total
transaction amount payable by you to the extent you elect to make a payment
using a credit or debit card or through an ACH transaction. If you do not wish
to pay the convenience fee, please contact Paulin Insurance Associates LLC for
other payment method options.


ORDER SUMMARY

   --------------------------------------------------------------------------------

 * Description
   -
 * Subtotal
   -


PAYMENT SUMMARY

   --------------------------------------------------------------------------------

 * Description
   -
   Convenience Fee-

   TOTAL DUE NOW
   
   -