new – The Agency Network LLC

Court Bond Premium Payment

"*" indicates required fields

Payor*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Bond Details

Power Number*

Full Power Number of Bond (ie PSC-XXXXXXXX)

Defendant Name*

As it appears on Bond

First Last

Agency Code*

Agent Name*

Agent Email*

Payment Information

For the convenience of our clients, we have partnered with The Agency Network, LLC, a third-party Billing Agent who specifically operates with credit card payments and collections for the Bail Bond industry. No refunds are given unless required by law.

Method*

Type*

Amount*

Total

Credit Card

Attestation and eSignature

The Agency Network, LLC is a third-party Billing Agent. No refunds are given unless required by law.

Attestation*

The Payee named has willfully and knowingly agreed with the Bail Agency for services requested and further acknowledged and allows The Agency Network, LLC to act as a third party Billing Agent on behalf of the named Bail Agency to collect the specified Bail Bond Premium Payment. All Premiums generated by the Bail Agency shall be earned, in their entirety, upon the production of such services. At NO time after the execution of such services provided shall the premium(s) enumerated become refundable unless otherwise denoted by the respective state laws governing such transaction.

I agree to the Terms of Service

Signature*

Unique ID