ClaimWizard Payment - Assignable •

ClaimWizard Company Account Information

Company Name*

Name of company that you would like this assignable account added to.

Company Code*

Your Name*

Your Company*

Your Email*

Your Phone Number*

Billing Address*

Street Address Address Line 2 City State ZIP Code

Your ClaimWizard Fee*

Total

You will be billed this amount on an annual or monthly basis, depending on the option you selected.

$0.00

Credit Card*

Card Details

Cardholder Name

Email

This field is for validation purposes and should be left unchanged.