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jgsinsurance.appliedpay.com Open in urlscan Pro
34.111.71.248  Public Scan

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Submitted URL: http://url7502.jgsinsurance.com/ls/click?upn=OtVfgkMRFf6-2FCBhguUV3pmJcWZNC0luMvOjt1PJizEtuljZFOdIVLD4EanyogyzHzsz4_jrUqf5zwH7Fz...
Effective URL: https://jgsinsurance.appliedpay.com/
Submission: On February 09 via manual from IN — Scanned from DE

Form analysis 1 forms found in the DOM

<form>
  <div class="flex-container">
    <div data-grid-row="true" class="Row_module_row__4ff93fa8 HostedPaymentPage_gapFix__crtOp">
      <div data-grid-col="true" class="Col_module_col__3625c59c Col_module_xs12__3625c59c Col_module_sm6__3625c59c">
        <div style="width: 100%;">
          <div data-test="firstNameTest">
            <div data-label="true" class="Label_module_label__3bbefa2d"><label for="firstName" class="required">First Name<div class="Label_module_requiredIcon__3bbefa2d">
                  <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__72b0899a" style="width: 100%;">
              <div class="TextField_module_innerWrapper__72b0899a"><input id="firstName" role="input" autocomplete="off" class="TextField_module_input__72b0899a" name="firstName" spellcheck="false" type="text" value="" style="text-align: left;">
              </div>
            </div>
          </div>
        </div>
      </div>
      <div data-grid-col="true" class="Col_module_col__3625c59c Col_module_xs12__3625c59c Col_module_sm6__3625c59c">
        <div style="width: 100%;">
          <div data-test="lastNameTest">
            <div data-label="true" class="Label_module_label__3bbefa2d"><label for="lastName" class="required">Last Name<div class="Label_module_requiredIcon__3bbefa2d">
                  <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__72b0899a" style="width: 100%;">
              <div class="TextField_module_innerWrapper__72b0899a"><input id="lastName" role="input" autocomplete="off" class="TextField_module_input__72b0899a" name="lastName" spellcheck="false" type="text" value="" style="text-align: left;"></div>
            </div>
          </div>
        </div>
      </div>
    </div>
    <div data-grid-row="true" class="Row_module_row__4ff93fa8 HostedPaymentPage_gapFix__crtOp">
      <div data-grid-col="true" class="Col_module_col__3625c59c Col_module_xs12__3625c59c">
        <div style="width: 100%;">
          <div data-test="businessNameTest">
            <div data-label="true" class="Label_module_label__3bbefa2d"><label for="businessName" class="">Business Name</label></div>
            <div class="TextField_module_wrapper__72b0899a" style="width: 100%;">
              <div class="TextField_module_innerWrapper__72b0899a"><input id="businessName" role="input" autocomplete="off" class="TextField_module_input__72b0899a" name="businessName" spellcheck="false" type="text" value=""
                  style="text-align: left;"></div>
            </div>
          </div>
        </div>
      </div>
    </div>
    <div data-grid-row="true" class="Row_module_row__4ff93fa8 HostedPaymentPage_gapFix__crtOp">
      <div data-grid-col="true" class="Col_module_col__3625c59c Col_module_xs12__3625c59c">
        <div style="width: 100%;">
          <div data-test="emailTest">
            <div data-label="true" class="Label_module_label__3bbefa2d"><label for="email" class="required">Email Address<div class="Label_module_requiredIcon__3bbefa2d">
                  <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__72b0899a" style="width: 100%;">
              <div class="TextField_module_innerWrapper__72b0899a"><input id="email" role="input" autocomplete="off" class="TextField_module_input__72b0899a" name="email" spellcheck="false" type="text" value="" style="text-align: left;"></div>
            </div>
          </div>
        </div>
      </div>
    </div>
    <div data-grid-row="true" class="Row_module_row__4ff93fa8 HostedPaymentPage_gapFix__crtOp"></div>
    <div data-grid-row="true" class="Row_module_row__4ff93fa8 HostedPaymentPage_gapFix__crtOp">
      <div data-grid-col="true" class="Col_module_col__3625c59c Col_module_xs12__3625c59c Col_module_sm6__3625c59c">
        <div style="width: 100%;">
          <div data-test="policyNumberTest">
            <div data-label="true" class="Label_module_label__3bbefa2d"><label for="policyNumber" class="">Policy Number</label></div>
            <div class="TextField_module_wrapper__72b0899a" style="width: 100%;">
              <div class="TextField_module_innerWrapper__72b0899a"><input id="policyNumber" role="input" autocomplete="off" class="TextField_module_input__72b0899a" name="policyNumber" spellcheck="false" type="text" value=""
                  style="text-align: left;"></div>
            </div>
          </div>
        </div>
      </div>
      <div data-grid-col="true" class="Col_module_col__3625c59c Col_module_xs12__3625c59c Col_module_sm6__3625c59c">
        <div style="width: 100%;">
          <div data-test="invoiceNumberTest">
            <div data-label="true" class="Label_module_label__3bbefa2d"><label for="invoiceNumber" class="">Invoice Number</label></div>
            <div class="TextField_module_wrapper__72b0899a" style="width: 100%;">
              <div class="TextField_module_innerWrapper__72b0899a"><input id="invoiceNumber" role="input" autocomplete="off" class="TextField_module_input__72b0899a" name="invoiceNumber" spellcheck="false" type="text" value=""
                  style="text-align: left;"></div>
            </div>
          </div>
        </div>
      </div>
    </div>
    <div data-grid-row="true" class="Row_module_row__4ff93fa8 HostedPaymentPage_gapFix__crtOp">
      <div data-grid-col="true" class="Col_module_col__3625c59c Col_module_xs12__3625c59c">
        <div style="width: 100%;">
          <div data-test="paymentDescriptionTest">
            <div data-label="true" class="Label_module_label__3bbefa2d"><label for="paymentDescription" class="required">Description<div class="Label_module_requiredIcon__3bbefa2d">
                  <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__72b0899a" style="width: 100%;">
              <div class="TextField_module_innerWrapper__72b0899a"><input id="paymentDescription" role="input" autocomplete="off" class="TextField_module_input__72b0899a" name="paymentDescription" spellcheck="false" type="text" value=""
                  style="text-align: left;"></div>
            </div>
          </div>
        </div>
      </div>
    </div>
    <div data-grid-row="true" class="Row_module_row__4ff93fa8 HostedPaymentPage_gapFix__crtOp">
      <div data-grid-col="true" class="Col_module_col__3625c59c Col_module_xs12__3625c59c">
        <div style="width: 100%;">
          <div data-test="amountTest">
            <div data-label="true" class="Label_module_label__3bbefa2d"><label for="amount__textField" class="required">Amount<div class="Label_module_requiredIcon__3bbefa2d">
                  <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__72b0899a" style="width: 100%;">
              <div data-test="amountTest-start-icon-wrapper" tabindex="-1" class="TextField_module_iconWrapper__72b0899a TextField_module_start__72b0899a TextField_module_nonClickable__72b0899a">
                <div class="Icon_module_wrapper__584d5c36" data-icon="DollarIcon"><svg height="16" width="16" class="Icon_module_icon__584d5c36 DollarIcon_module_fill__8d097241" viewBox="0 0 16 16" fill="none" xmlns="http://www.w3.org/2000/svg">
                    <path fill-rule="evenodd" clip-rule="evenodd"
                      d="M8.665 2.64999C8.665 2.28272 8.36727 1.98499 8 1.98499C7.63273 1.98499 7.335 2.28272 7.335 2.64999V3.28676C7.13072 3.30683 6.93158 3.33949 6.73929 3.38395C5.47012 3.67734 4.25 4.5841 4.25 5.99998C4.25 6.99857 4.85977 7.67297 5.56824 8.0775C6.09164 8.37636 6.71562 8.56147 7.335 8.66753V11.1448C6.62104 11.0251 5.82349 10.7662 4.99748 10.3351C4.63027 10.1434 4.17722 10.2857 3.98557 10.653C3.79391 11.0202 3.93622 11.4732 4.30343 11.6649C5.33514 12.2033 6.3732 12.5323 7.335 12.6617V13.3499C7.335 13.7172 7.63273 14.015 8 14.015C8.36727 14.015 8.665 13.7166 8.665 13.3494V12.7106C8.83808 12.6985 9.00654 12.6786 9.16975 12.6511C9.85988 12.5347 10.497 12.2735 10.9734 11.8346C11.4648 11.382 11.75 10.77 11.75 10.0577C11.75 8.97637 11.0043 8.28921 10.2926 7.90126C9.77725 7.62039 9.19228 7.44175 8.665 7.33996V4.86154C9.18119 4.98163 9.71302 5.21705 10.2144 5.5972C10.5445 5.84745 11.015 5.78273 11.2652 5.45266C11.5155 5.12258 11.4507 4.65214 11.1207 4.40189C10.3414 3.81107 9.49187 3.46951 8.665 3.33302V2.64999ZM7.335 4.79728C7.24672 4.80998 7.16065 4.8261 7.07713 4.8454C6.12957 5.06445 5.75 5.59353 5.75 5.99998C5.75 6.28295 5.89374 6.53605 6.31202 6.77489C6.58607 6.93137 6.93852 7.05392 7.335 7.14001V4.79728ZM8.665 8.87598V11.2055C8.75304 11.1971 8.83822 11.1858 8.92034 11.172C9.41099 11.0893 9.75137 10.9209 9.95718 10.7314C10.1481 10.5555 10.25 10.3401 10.25 10.0577C10.25 9.77595 10.0738 9.4904 9.57469 9.21833C9.30233 9.06988 8.98285 8.95624 8.665 8.87598Z">
                    </path>
                  </svg></div>
              </div>
              <div class="TextField_module_innerWrapper__72b0899a"><input id="amount__textField" role="input" autocomplete="off" class="TextField_module_input__72b0899a TextField_module_startingIcon__72b0899a" name="amount__textField"
                  spellcheck="false" type="text" value="" style="text-align: left;"></div>
            </div>
          </div>
        </div>
      </div>
    </div>
  </div>
</form>

Text Content

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MAKE A PAYMENT

Enter your payment information below.

First Name


Last Name


Business Name

Email Address



Policy Number

Invoice Number

Description


Amount


Next
 * Name
   
 * Business Name
   -
 * Email Address
   
 * Policy Number
   -
 * Invoice Number
   -
 * Description
   -

 * Subtotal
   
 * Convenience Fee
   
 * Total
   

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PAYMENT METHOD

Use Payment Method on File



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 JGS Insurance for other payment
method options.



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