Completing this form authorizes Vertafore FSC, Inc. to initiate a charge to my Visa, MasterCard, or American Express in the amount listed below. I understand that this is a one-time authorization and must be completed each time that I wish to make payment.

For your security, all payment information is transmitted using a secure connection. Payments will be posted to your account within one business day. Upon successful transmission of your payment request you will receive a confirmation email. In the event that you do not receive a confirmation, please contact us at (800) 433-2550.

Credit Card Billing Information

  FSC Customer Number:

 *

  FSC Customer Number:

 * (Re-enter for verification)

  Name (on credit card):

 *

  Billing Address:

 *

  Billing City:

 *

  Billing State:

 *

  Billing Zip Code:

 *

  Phone Number:

 * (999-999-9999)

  Email Address:

 *
  * Denotes Required Field

Agency Information (if different from above)

  Agency Name:      

*

  Address:

  City:

  State:

  Zip Code:

  Phone Number:

  (999-999-9999)

For any additional comments or questions, please email us.

Payment Information

Select the form of payment
Enter the amount you wish to pay $
Only for FSC Rater, FSC Rater RT, MI-Rater RT, FSC INStream, WebFSC, and FSC Manager