Billing Information  
 
  
Invoice/Stmt# or Policy#
   Dr/Practice Name
  
Company Name (optional)
  
First Name
 
MI
 
Last Name
   Address
  
  
City
  
State
  
Zip Code
  
Phone
  
Work Phone
  
E-mail (required for an emailed receipt)
  
 
   Payment Information  
  

Payment Amount
 
  Please select a payment method
Checking Savings
  Notes

 
 
Your Invoice/Statement # is located on the top right corner of your Invoice/Statement. Your policy # is located near the middle, lefthand side. Any of these numbers may be used to associate this transaction with your premium payment.

Please enter a contact person's name and address on the required fields so they may be contacted regarding any questions about the submitted payment.

Payments must be submitted by 6:oo p.m. central time to be debited from your account the following day and will subsequently be processed by PPIC® within 3-5 business days. All refunds due to an overpayment, incorrect payment, etc. will be issued by check.

PPIC® is providing this on-line payment option as a convenience to you. In utilizing this on-line payment option you have agreed to the terms and conditions as set out by Modern Payments. In the event that your payment is returned or otherwise not processed, you are still responsible for your timely premium payment to PPIC®. PPIC® is in no way responsible for the security or accuracy of any transactions between you, Modern Payments, or your financial institution.


This is a secure site. All of your information is secure and confidential.