gallagheraffinity.epaypolicy.com
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2606:4700::6812:b20
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Submitted URL: http://payonline.gallagher-affinity.com/
Effective URL: https://gallagheraffinity.epaypolicy.com/
Submission: On August 13 via api from JP — Scanned from JP
Effective URL: https://gallagheraffinity.epaypolicy.com/
Submission: On August 13 via api from JP — Scanned from JP
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 Number</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="TransactionAttribute4884" data-valmsg-replace="true"></span>
<span class="field-validation-error" style="display:none" data-valmsg-for="TransactionAttribute4884" data-valmsg-replace="true">The Invoice Number field is required.</span>
<input name="TransactionAttribute4884" class="form-control full " data-bind="textInput: TransactionAttribute4884" data-toggle="popover" data-trigger="manual focus" id="TransactionAttribute4884" onblur="validateCustomAttribute(event)"
pattern="(.*?)" placeholder="Invoice Number" 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>Account Number</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="TransactionAttribute4885" data-valmsg-replace="true"></span>
<span class="field-validation-error" style="display:none" data-valmsg-for="TransactionAttribute4885" data-valmsg-replace="true">The Account Number field is required.</span>
<input name="TransactionAttribute4885" class="form-control full " data-bind="textInput: TransactionAttribute4885" data-toggle="popover" data-trigger="manual focus" id="TransactionAttribute4885" onblur="validateCustomAttribute(event)"
pattern="(.*?)" placeholder="Account Number" 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('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>
<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>
</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('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>
<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>
</div>
<div class="payment-ui-card-wrapper left-tab" data-bind="visible: paymentMethod() == 'CreditCard'">
<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'" 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(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'">
<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="" required="required">
</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="" required="required">
<!-- 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="" required="required">
</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="" required="required">
</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="" required="required">
</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="" 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" data-val="true" data-val-required="The SavePaymentOption field is required." id="SavePaymentOption" name="SavePaymentOption" type="checkbox" value="true"><input
name="SavePaymentOption" type="hidden" value="false">
<label for="SavePaymentOption">Save my card for future use</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-lg-9 col-md-9 col-sm-9 right" data-bind="visible: paymentMethod() == 'Ach'" style="display: none;">
<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="">
</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="">
</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="">
</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="">
</div>
</div>
<div class="row" data-bind="if: paymentMethod() == 'Ach'"></div>
</div>
</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="Please enter in the agency Id, policy number, quote number, or invoice number" rows="5" required="required"></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 Gallagher Affinity Insurance Services, Inc. to debit my account. <span data-bind="visible: payerFee() > 0" style="display: none;"> 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')">$0.00</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-cffkz4r9oy2d" 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=aHR0cHM6Ly9nYWxsYWdoZXJhZmZpbml0eS5lcGF5cG9saWN5LmNvbTo0NDM.&hl=ja&v=_ZpyzC9NQw3gYt1GHTrnprhx&size=normal&cb=41tf6d5vpr3s"></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="CreditCard">
<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="Tu1Vr-cd31nE3OzId8_VE8fblLOm6UEd9eQ2SMtwqcRzfTBUjD28IpT_tsIi7zpVh6XsY6_xsP-4PJhA8Gcro4ZxGck1">
<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 and
disclosure statement.</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 Number The Invoice Number field is required. Account Number The Account Number 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 CREDIT CARD Amount $0.00 Fee Enter Amount Total $0.00 ACH Amount $0.00 Fee Enter Amount Total $0.00 CREDIT CARD ACH Amount $0.00 Fee Enter Amount Total $0.00 Amount $0.00 Fee Enter Amount Total $0.00 Payment Information Save my card for future use 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 Gallagher Affinity Insurance Services, Inc. to debit my account. I understand that this payment each of the payments includes a $0.00 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 and disclosure statement. Digitally sign the Premium Finance Agreement Name Phone Number Email Address Download Agreement Cancel Agree × Cancel Confirm × OK