Notice to policyholders in the Southeast recently affected by Hurricane Helene and/or Hurricane Milton. 

Please note, our Payment Portal for malpractice premiums will be down for scheduled maintenance the evening of December 6 through December 7, 2024.

Credit Card Processing Express Request Application

Please complete the following information to receive a no-obligation comparison or quote. Information is required unless noted as optional. When finished, click "Submit Request” at the bottom of the page.

All fields marked with * are required.

Your Contact Information

(This Program is not available in Puerto Rico, Guam or Virgin Islands.)

 
 

Quote Information

Do you currently accept credit cards? *

Statement

It's easy to upload your most recent credit card processing statement for a free, no-obligation comparison.

Do you have your current statement? *

Upload
Important: Please scan all pages of your processing statement prior to uploading. If you're having trouble uploading, print this cover sheet and fax it.
No problem, we'll still send you a no-obligation quote.

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