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Payment_Test
Keith
2020-10-20T23:46:24-04:00
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Please contact Omega Benefit Strategies at
(508) 507-7481
or premium@omegabfs.com for assistance.
Scroll down to the bottom to confirm your recurring payment.
Group Name*
First Name*
Last Name*
Email*
Phone*
Billing Address 1*
Billing Address 2*
Billing Zip Code*
Billing City
Billing State
Social Security #*
Recurrence*
Select Recurrence
Premium Cost*
Administrative Fee
Total
Deduction Effective Date*
I authorize Omega Benefit Strategies, LLC (OBS) to charge my account information provided herein. I understand that this authorization will remain in effect until (a) I cancel the agreement, in writing, with OBS, or (b) my bank and/or OBS notifies me that the agreement has been terminated. The premium amount displayed is the quoted rate(s) for the plan coverage(s) and the Administrative Fee is the cost to collect and process the premium(s). Should premium cost(s) change OBS is authorized to charge the new premium cost to my account. Should premium collection and processing fees change OBS is authorized to charge the new Administrative Fee to my account.
For ACH debits to my checking account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted transaction date. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. OBS will not be liable in any manner for damages incurred at any time for insufficient funds or any other circumstances beyond the control of OBS or my bank.
If paying by credit card, I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement and that I am the authorized user of this payment card.
I have read and accepted the Processing Terms and Conditions
Processing Terms and Conditions
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