Continental Loss Adjusters

	E-Payment

Use our e-payment option. It's fast, easy, and secure

Company Name:
Address:
City:
State:
Country:
Zip:
Phone Number:
Email Address:
Insured:
Policy Number:
Claim Number:

Name on Card:
Card Type:
Credit Card Number:
Expiration Date:
Credit Card CVV Number:	( The three digit Card Verification number (CVV) is printed on the signature panel on the back of the card, just after the account number.)

Payment Type:
Payment Amount:
Payment Comments:


By submitting this form, I certify that I am authorized to make payment on behalf of the company, and I hereby authorize Continental Loss to charge the above amount to the credit card listed above