Employee Medical/Dental Premium Payment

Employee Medical/Dental premium payments may be made using the secure form below.

This form uses HTTPS for secure data transmission.

Full Name: *
Date of Birth: *
Last 4 Digits of SSN: *
Phone: *
Email: *
Medical/Dental Premium Amount: * Do not enter a dollar sign

Accepted Cards

Credit Card Number: *
Expiration Date & CVV: *	/

Please TRIPLE check the amount entered for accuracy. Overpayments may reserve funds on your card and could take several business days to refund.

Press the payment button only ONCE and allow time to process. Pressing multiple times may cause a double charge!