{"id":33,"date":"2024-05-24T20:52:56","date_gmt":"2024-05-24T20:52:56","guid":{"rendered":"https:\/\/payment.palmettosurety.com\/invoice\/?page_id=33"},"modified":"2024-12-08T16:08:15","modified_gmt":"2024-12-08T16:08:15","slug":"home","status":"publish","type":"page","link":"https:\/\/payment.palmettosurety.com\/invoice\/","title":{"rendered":"Home"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"33\" class=\"elementor elementor-33\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-f3a11f1 e-flex e-con-boxed e-con e-parent\" data-id=\"f3a11f1\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5bb5589 elementor-widget elementor-widget-text-editor\" data-id=\"5bb5589\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<!-- wp:gravityforms\/form {\"formId\":\"1\",\"inputPrimaryColor\":\"#204ce5\"} \/-->\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c872418 elementor-widget elementor-widget-heading\" data-id=\"c872418\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">AGENCY PAYMENT PORTAL<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-8b99838 e-flex e-con-boxed e-con e-parent\" data-id=\"8b99838\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-727cc6e elementor-widget elementor-widget-heading\" data-id=\"727cc6e\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\"><a href=\"https:\/\/payment.palmettosurety.com\/invoice\/agencency-credit-card-payments\/?\">Use this form to pay with Credit Card<\/a><\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-d598cab elementor-widget elementor-widget-shortcode\" data-id=\"d598cab\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\">\n                <div class='gf_browser_chrome gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_1' style='display:none'><style>#gform_wrapper_1[data-form-index=\"0\"].gform-theme,[data-parent-form=\"1_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg width='640' height='640' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/invoice\/wp-json\/wp\/v2\/pages\/33' data-formid='1' novalidate><input type=\"hidden\" name=\"gpuid_existing_value_36\" id=\"gpuid_existing_value_36\" value=\"a5f482110d578853687f0e1ff0fbd69d\" \/><input name=\"geolocation_submitter_location\" id=\"geolocation_submitter_location\" type=\"hidden\" data-js=\"geolocation_submitter_location\" value=\"\" \/>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_1_38\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Agency Information<\/h3><\/div><div id=\"field_1_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'>Agency Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_1_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'>Agency Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_1_23' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_7\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_7'>\n                            \n                            <span id='input_1_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_1_7_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_7.3' id='input_1_7_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            \n                            <span id='input_1_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_1_7_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_7.6' id='input_1_7_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_21\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_21'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_21' id='input_1_21' type='tel' value='' class='medium'  placeholder='((XXX) XXX-XXXX' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_9\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_9' id='input_1_9' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                        <\/div><\/div><fieldset id=\"field_1_14\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Billing Address<\/legend><div class='gfield_description' id='gfield_description_1_14'>Please enter the address associated with your Bank Account <\/div>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_14' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_14_1_container' >\n                                        <label for='input_1_14_1' id='input_1_14_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_14.1' id='input_1_14_1' value=''    aria-required='false'   autocomplete=\"address-line1\" \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_14_2_container' >\n                                        <label for='input_1_14_2' id='input_1_14_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_14.2' id='input_1_14_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_14_3_container' >\n                                    <label for='input_1_14_3' id='input_1_14_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_14.3' id='input_1_14_3' value=''    aria-required='false'   autocomplete=\"address-level2\" \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_14_4_container' >\n                                        <label for='input_1_14_4' id='input_1_14_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <select name='input_14.4' id='input_1_14_4'     aria-required='false'   autocomplete=\"address-level1\" ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_14_5_container' >\n                                    <label for='input_1_14_5' id='input_1_14_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                    <input type='text' name='input_14.5' id='input_1_14_5' value=''    aria-required='false'   autocomplete=\"postal-code\" \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_14.6' id='input_1_14_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_coords_14\" class=\"gform_hidden\" value=\"\"><\/fieldset><div id=\"field_1_37\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Payment Information<\/h3><\/div><fieldset id=\"field_1_40\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-three-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Defendant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_40'>\n                            \n                            <span id='input_1_40_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_40.3' id='input_1_40_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_40_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_40_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_40.6' id='input_1_40_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_40_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_41'>Power Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_1_41' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-product gfield--input-type-price gfield--width-third gfield_price gfield_price_1_30 gfield_product_1_30 gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>Invoice Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_product_price'>\n\t\t\t\t\t<input name='input_30' id='input_1_30' type='text' value='' class='medium ginput_amount'  placeholder='$' aria-required=\"true\" aria-invalid=\"false\"  \/>\n\t\t\t\t<\/div><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-total gfield--input-type-total gfield--width-third gfield_price gfield_price_1_ gfield_total gfield_total_1_ field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" ><label class='gfield_label gform-field-label' for='input_1_3'>Total  Amount of Payment<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_3' id='input_1_3' value='$0.00' class='gform-text-input-reset ginput_total ginput_total_1' \/>\n\t\t\t\t\t\t<\/div><\/div><div id=\"field_1_44\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_44'>Payment Method<\/label><div class='ginput_container ginput_container_select'><select name='input_44' id='input_1_44' class='large gfield_select'     aria-invalid=\"false\" ><option value='ACH DEBIT' >ACH DEBIT<\/option><option value='CREDIT CARD' >CREDIT CARD<\/option><\/select><\/div><\/div><fieldset id=\"field_1_42\" class=\"gfield gfield--type-ach gfield--input-type-ach gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gfield_label_before_complex' >ACH<\/legend><div class='ginput_complex ginput_container ginput_container_ach' id='input_1_42'><span class='ginput_left' id='input_1_42_1_container' >\r\n\t\t\t\t\t\t\t\t\t<label for='input_1_42_1' id='input_1_42_1_label' >Account Number<\/label>\r\n\t\t\t\t\t\t\t\t\t<input type='text'  id='input_1_42_1' value=''     autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='false'  \/>\r\n\t\t\t\t\t\t\t\t <\/span><span class='ginput_right' id='input_1_42_3_container'>\r\n                                    <label for='input_1_42_3' id='input_1_42_3_label' >Account Type<\/label>\r\n\t\t\t\t\t\t\t\t\t<select name='input_42.3' id='input_1_42_3'   class='ginput_card_expiration' aria-required='false'  >\r\n\t\t\t\t\t\t\t\t\t\t<option value=''>Select<\/option><option value='S' >Savings<\/option><option value='C' >Checking<\/option>\r\n\t\t\t\t\t\t\t\t\t<\/select>\r\n                                 <\/span><span class='ginput_full' id='input_1_42_2_container' >\r\n                                    <label for='input_1_42_2' id='input_1_42_2_label' >Routing Number<\/label>\r\n                                    <input type='text'  id='input_1_42_2' value=''     autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='false'  \/>\r\n                                 <\/span><span class='ginput_full' id='input_1_42_4_container'>\r\n                                            <label for='input_1_42_4' id='input_1_42_4_label' >Account Holder Name<\/label>\r\n                                            <input type='text'  id='input_1_42_4' value=''    aria-required='false'  \/>\r\n                                        <\/span> <\/div><\/fieldset><fieldset id=\"field_1_43\" class=\"gfield gfield--type-creditcard gfield--input-type-creditcard gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Credit Card<\/legend><div class='ginput_complex ginput_container ginput_container_creditcard gform-grid-row' id='input_1_43'><span class='ginput_full gform-grid-col' id='input_1_43_1_container' >\n                                    <div class='gform_card_icon_container'><div class='gform_card_icon gform_card_icon_amex' >American Express<\/div><div class='gform_card_icon gform_card_icon_discover' >Discover<\/div><div class='gform_card_icon gform_card_icon_mastercard' >MasterCard<\/div><div class='gform_card_icon gform_card_icon_visa' >Visa<\/div><span class='screen-reader-text' id='field_1_43_supported_creditcards'>Supported Credit Cards: American Express, Discover, MasterCard, Visa<\/span><\/div>\n                                    <label for='input_1_43_1' id='input_1_43_1_label' class='gform-field-label gform-field-label--type-sub '>Card Number<\/label>\n                                    <input type='text'  id='input_1_43_1' value=''   onchange='gformMatchCard(\"input_1_43_1\");' onkeyup='gformMatchCard(\"input_1_43_1\");' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='false'  \/>\n                                 <\/span><span class='ginput_full ginput_cardextras gform-grid-col gform-grid-row' id='input_1_43_2_container'>\n                                            <fieldset class='ginput_cardinfo_left gform-grid-col' id='input_1_43_2_cardinfo_left'>\n                                            <legend class='gform-field-label gform-field-label--type-sub '>Expiration Date<\/legend>\n                                                <span class='ginput_card_expiration_container ginput_card_field gform-grid-row'>\n                                                   <span class='ginput_card_expiration_month_container gform-grid-col'>\n                                                       <label for='input_1_43_2_month' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                                       <select  id='input_1_43_2_month'   class='ginput_card_expiration ginput_card_expiration_month' aria-required='false'  >\n                                                           <option value=''>Month<\/option><option value='1' >01<\/option><option value='2' >02<\/option><option value='3' >03<\/option><option value='4' >04<\/option><option value='5' >05<\/option><option value='6' >06<\/option><option value='7' >07<\/option><option value='8' >08<\/option><option value='9' >09<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option>\n                                                       <\/select>\n                                                   <\/span>\n                                                   <span class='ginput_card_expiration_year_container gform-grid-col'>\n                                                       <label for='input_1_43_2_year' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                                       <select  id='input_1_43_2_year'   class='ginput_card_expiration ginput_card_expiration_year' aria-required='false'  >\n                                                           <option value=''>Year<\/option><option value='2026' >2026<\/option><option value='2027' >2027<\/option><option value='2028' >2028<\/option><option value='2029' >2029<\/option><option value='2030' >2030<\/option><option value='2031' >2031<\/option><option value='2032' >2032<\/option><option value='2033' >2033<\/option><option value='2034' >2034<\/option><option value='2035' >2035<\/option><option value='2036' >2036<\/option><option value='2037' >2037<\/option><option value='2038' >2038<\/option><option value='2039' >2039<\/option><option value='2040' >2040<\/option><option value='2041' >2041<\/option><option value='2042' >2042<\/option><option value='2043' >2043<\/option><option value='2044' >2044<\/option><option value='2045' >2045<\/option>\n                                                       <\/select>\n                                                   <\/span>\n                                                <\/span>\n                                            <\/fieldset><span class='ginput_cardinfo_right gform-grid-col' id='input_1_43_2_cardinfo_right'>\n                                                <label for='input_1_43_3' class='gform-field-label gform-field-label--type-sub '>Security Code<\/label>\n                                                <input type='text'  id='input_1_43_3'   class='ginput_card_security_code' value='' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='false'  \/>\n                                                <span class='ginput_card_security_code_icon'>&nbsp;<\/span>\n                                             <\/span>\n                                        <\/span><span class='ginput_full gform-grid-col' id='input_1_43_5_container'>\n                                            <label for='input_1_43_5' id='input_1_43_5_label' class='gform-field-label gform-field-label--type-sub '>Cardholder Name<\/label>\n                                            <input type='text'  id='input_1_43_5' value=''    aria-required='false'  \/>\n                                        <\/span> <\/div><\/fieldset><div id=\"field_1_39\" class=\"gfield gfield--type-section gfield--input-type-section gsection exclude field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Attestation<\/h3><\/div><fieldset id=\"field_1_17\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full exclude gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >CONSENT, I AGREE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_17' tabindex='0'>By submitting this form, you give Palmetto Surety Corporation or its Agent full permission to charge or debit your selected payment method for the above amount on or after the indicated date. This permission granted is for this single transaction only. I understand that the payments may be executed on the next business day. For ACH debits to my checking\/savings account, I know that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above-noted regular transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF), I understand that the merchant may, at its discretion, attempt to process the charge again within 30 days and agree to an additional $100.00 charge for each attempt to return NSF which will be initiated as a separate transaction from the authorized recurring payment. I also acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card\/bank account and will not dispute these scheduled transactions with my bank or credit card company so long as the transactions correspond to the terms indicated in this authorization form.<\/div><div class='ginput_container ginput_container_consent'><input name='input_17.1' id='input_1_17_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_17\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_17_1' ><p><span><span style=\"text-decoration: underline;\"><strong>CLICK HERE<\/strong><\/span> to accept hat <\/span>you agree to be legally bound by the transaction terms below, our <span style=\"text-decoration: underline;\"><strong><a href=\"https:\/\/pay.palmettosurety.com\/return-policy\/\">Refund Policy<\/a><\/strong><\/span>, and <span style=\"text-decoration: underline;\"><strong><a href=\"https:\/\/www.palmettosurety.com\/privacy-policy\/\">Privacy Policy<\/a><\/strong><\/span><\/p><\/label><input type='hidden' name='input_17.2' value='&lt;p&gt;&lt;span&gt;&lt;span style=&quot;text-decoration: underline;&quot;&gt;&lt;strong&gt;CLICK HERE&lt;\/strong&gt;&lt;\/span&gt; to accept hat &lt;\/span&gt;you agree to be legally bound by the transaction terms below, our &lt;span style=&quot;text-decoration: underline;&quot;&gt;&lt;strong&gt;&lt;a href=&quot;https:\/\/pay.palmettosurety.com\/return-policy\/&quot;&gt;Refund Policy&lt;\/a&gt;&lt;\/strong&gt;&lt;\/span&gt;, and &lt;span style=&quot;text-decoration: underline;&quot;&gt;&lt;strong&gt;&lt;a href=&quot;https:\/\/www.palmettosurety.com\/privacy-policy\/&quot;&gt;Privacy Policy&lt;\/a&gt;&lt;\/strong&gt;&lt;\/span&gt;&lt;\/p&gt;' class='gform_hidden' \/><input type='hidden' name='input_17.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_33\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_33'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_33_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><input type='hidden' class='gform_hidden' name='input_1_33_valid' id='input_1_33_valid' \/><canvas id='input_1_33' width='600' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_1_34\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_34'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input readonly='readonly' name='input_34' id='input_1_34' type='text' value='05\/22\/2026' class='gpro-disabled-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_34_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_34_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <input type=\"hidden\" id=\"gwro_hidden_capture_1_34\" name=\"gwro_hidden_capture_1_34\" value=\"05\/22\/2026\" class=\"gf-default-disabled\" \/><\/div>\n                        <input readonly='readonly' type='hidden' id='gforms_calendar_icon_input_1_34' class='gform_hidden' value='https:\/\/payment.palmettosurety.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_35'>Authorizing IP<\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_35' id='input_1_35' type='text' value='103.4.250.103' class='large'    placeholder='103.4.250.103'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-uid gfield--input-type-uid gfield--width-third exclude field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><label class='gfield_label gform-field-label' for='input_1_36'>Receipt Number<\/label><div 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);\n<\/script>\n<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>AGENCY PAYMENT PORTAL Use this form to pay with Credit 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