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Personal Information

Required

Please enter your personal information. All fields but Organization are required.

Mailing Address

Required

Please enter your mailing address. Currently only United States and Canadian addresses are supported.

Billing Address

Required

Please enter your billing address. This should be the same address that is assigned to your payment information. Currently only United States and Canadian addresses are supported.

Payment Information

Required

Use one of the tabs to select your payment information. If you are paying by ECheck then your bank account must be funded by United States sources.

First Name

Required

Maximum length is 30 characters.

Last Name

Required

Maximum length is 30 characters.

Organization

Optional

Maximum length is 30 characters.

Phone Number

Required

Currently only U.S. and Canadian numbers are supported.

Please enter all digits with no spaces or special charcters.

Maximum length is 10 digits.

Email Address

Required

Enter your email address.

Maximum length is 50 characters.

Address Line 1

Required

Maximum length is 30 characters.

Address Line 2

Optional

Maximum length is 20 characters.

City

Required

Maximum length is 20 characters.

State or Province

Required

Your selected state or province must match your selected country.

Postal Code

Required

Currently only U.S. and Canadian postal codes are supported.

Maximum length is 9 characters.

Country

Required

Your selected state or province must match your selected country.

Name on Card

Required

Enter the name exactly as it is printed on the card.

Maximum length is 40 characters.

Credit Card Number

Required

Please enter all digits with no spaces or special characters.

Maximum length is 20 characters.

Credit Card Type

Required

Select the credit card type. Only the supported card types are listed.

Expiration Date and Month

Required

Select the Credit card's expiration month and year.

The credit card must not have expired.

International ACH Transaction ("IAT") *

If you checked this box, then you are saying that this account is funded according to the decription below. NIC Services and BrickStreet Insurance do not not currently accept ACH payments specifically funded by a foreign source (bank or company), an International ACH Transaction ("IAT").

You may UNCHECK this box and enter account information that is funded outside the territorial United States.

You may also simply enter a credit card

Please contact Brickstreet Insurance for instructions if you still wish to make an ACH payment.

* As defined by NACHA, IAT means a credit or debit entry that is part of a payment transaction involving a financial agency's office that is not located in the territorial jurisdiction of the United States.

For purposes of this definition a financial agency means an entity that is authorized by applicable law to accept deposits or is in the business of issuing money orders or transferring funds.

An office of a financial agency is involved in the payment transaction if it:

Holds an account that is credited or debited as part of the payment transaction;
Receives payment directly from a Person or makes payment directly to a Person as part of the payment transaction; or
Serves as an intermediary in the settlement of any part of the payment transaction.

Bank Name

Required

Name of the Bank managing your account.

Maximum length is 30 characters.

Account Type

Required

Select an account type. Only supported types are listed.

Routing Number

Required

Your bank's routing number.

Maximum length is 9 characters.

Account Number

Required

The account number you want us to use.

Maximum length is 20 characters.