Success You have successfully added automatic payments from your checking account.
Success You successfully made a payment of $332.00 on Month Day, Year. Your payment will be processed in 2 - 3 days.
Success You have successfully deleted automatic payments. Your insurance bill will no longer be paid automatically. You will be required to pay your bill manually.
Success You successfully made a payment of $332.00 on Month Day, Year. Your payment will be processed in 3 - 5 days.
Success You have chosen to submit your payment via mail. Don't forget to mail your statement along with your check. Your Payment History and associated statement will reflect your payment once we receive and process your check. This typically takes from 5 – 10 business days.
Statement
Due Date
Past Due
Current Balance
Total Due
Auto-Pay
$0.00
$332.00
$332.00
Auto-Pay: OFF
Past Due You must pay your past due amount of $125.00 by January 14, 2020, or you may lose coverage.
Payment Required First automatic payment will occur on 1, . Ensure that you make a payment for the statement due on 1, .
Add Auto-Pay
Payment Method
Account Type
Bank routing number:
Institution Name:
Account number:
Note: First automatic payment will occur on 1, . Ensure that you make a payment for the statement due on 1, .
Edit Auto-Pay
Payment Method
Account Type
Bank routing number:
Institution Name:
Bank Name
Account number:
Note: First automatic payment will occur on 1, . Ensure that you make a payment for the statement due on 1, .
Pat Smith (111111111) 123 Main St. Anytown, CA 99999 (555)555-1212
Account Number
123456789
Payment Due Date
05/01/
For coverage period
05/01/ – 05/31/
Amount Due
$332.00
Total Enclosed
$
Make check or money order payable to: ITDR
Mail your payment to: ITDR P.O. Box 123 Anytown, CA 99999
Post Date
Description
Benefit
Amount
04/15/
Charge
Medical Plan
$212.00
04/15/
Charge
Dental Plan
$50.00
04/15/
Charge
Medical Plan - Medicare
$70.00
Details - Month, Year
Pat Smith (111111111) 123 Main St. Anytown, CA 99999 (555)555-1212
Account Number
123456789
Payment Due Date
For coverage period
–
Amount Due
$0.00
Thank you for your payment!
Post Date
Description
Benefit
Amount
Charge
Medical Plan
$212.00
Charge
Dental Plan
$50.00
Charge
Medical Plan - Medicare
$70.00
Payment
($332.00)
Receipt
Terry Smith
123 Main St.
Anytown, CA 99999
Received
Amount
$332.00
Method
Direct Debit
Coverage
Coverage Dates
Medical Plan
-
Dental Plan
-
Medical Plan - Medicare
-
Convenience Fee
You agree to and authorize a $10.00 convenience fee being added to your premium balance due. Additionally, you agree and authorize that you will make your payment based on seeing that combined total amount (premium balance due plus convenience fee) on the next screen, where payment is actually transacted. (You also agree that having a completed payment refunded or canceled will subject you to an additional $10.00 convenience fee charge.)
Delete Auto-Pay Information
Are you sure you want to delete your auto-pay settings?
If you delete your auto-pay settings, your insurance bill will no longer be paid automatically. You will be required to pay your bill manually.