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Protection Plus
Digital Biling Form
Complete the form below to manually add new Payment Methods into Salesforce
Billing Information
TPP Employee Name
*
ERO First Name
*
ERO Last Name
*
ERO Email Address
*
Notes
*
EFIN Information
EFIN
*
Missing EFIN?
Payment Information
Payment Method
Credit Card
ACH (Bank Transfer)
Credit Card Information
Preferred Location
*
Select preferred payment method location
Primary
Secondary
Other
Insurance
Set preferred location to Insurance as well?
Would you like to submit this as a one-time payment method?
Payment Request
Would you like to submit a one-time payment request to the billing team for this new Payment Method?
Please double check for accuracy and correct any errors before submitting.
First name is required
Last name is required
EFIN must be exactly 6 digits