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Make a Payment Online

Quickly and easily make a payment directly to us by completely filling out the form below. Click the Submit button when finished.

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Name
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E-Mail Address
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Street Address
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City
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State
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Phone Number
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Payment Type
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Account Number
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Credit card operators and processing companies require merchants to pay a fee if merchant wishes to accept card payments. Premium, policy fee, or tax due has to be forwarded to the Insurer, or the State, or its representatives in full. Agency is unable sponsor portion of the amount due in order to make card payment feature available to you, unless you agree to cover a small convenience fee. 

For payments made via American Express, Visa, Master Card, and Discover convenience, a fee of 3% will be added to the net amount requested for payment.

For payments made via ACH/eCheck, a single $5.00 fee will be added to the net amount requested for payment. Automatic recurring EFT payments are available and require written signed agreement - please contact our office to request blank enrollment form. When you request payment by submitting this form, you agree to the terms and conditions above and below:
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I authorize Choice One Insurance, Inc. and its employees ("Agency") to initiate deduction from the bank account, identified below, for payment of premium, taxes, membership dues, and service fees, including any renewals thereof, and to initiate credit entries to the account to correct any erroneous deductions or provide a refund on my account with Agency. 

I authorize the financial institution identified by the routing number below to accept and post entries to the account. I represent that I am the owner and/or an authorized signer on the account. I understand that this authorization allows Agency to adjust deductions to reflect any premium, tax, dues and/or fee changes.

I understand that Agency will not send me a bill before deduction is made and that it is my responsibility to ensure sufficient funds are in the account at the time of deduction. I also understand that my policy, membership, or service may cancel or expire if there are insufficient funds in the account and that every such non-sufficient fund transaction will be subject to $25.00 fee per occurrence posted to my account with Agency. Agency will not be responsible for any fees my financial institution charges to my bank account for insufficient funds transaction nor Agency will be liable for any payment requests I make in error due to misunderstanding of terms of service.

I furthermore agree that $5.00 service fee will be added to the total amount requested for payment. I understand and acknowledge that each payment request I submit may be done in writing, electronically, or verbally in person or over the telephone.

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Once this payment form submitted, convenience fee deemed to be fully earned and cannot be returned/credited/refunded. Please press submit button only once to avoid duplicate charges made to your account. Please note that all payments processed as credit to your account and applied to oldest balance owed.

“By submitting my payment request via this page I declare that I am the person shown on the bank account or credit card being submitted for payment and I give my full consent to the convenience fee added to payment amount and agree to pay this fee while understanding that the fee is non-refundable.

 













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 Licensed in: OR, WA, ID, NV, SC, NC, GA. CA license # 0I29732, Choice One Insurance Agency