Premium Payment

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The Eric Blair Network is pleased to offer this service of payment by credit card over Internet.

Nethertheless, in order for us to assign each payment to the appropriate client and policy we request that the following information is completed:

Office / Bureau(required)

Email address / email(required)

Assured Name / Nom de l'assuré(required)

Amount in € / Montant en €(required)

Please use the following format 100.50€ - NOT A COMMA (,) BUT a DOT(.)

Policy Number / N° de Contrat(required)

Policy period / Période

Company / Société

Invoice Number / N° de facture

Please recopy this validation code into the field / Merci de recopier ce code avant validation(required)

This field should be left blank

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