Business Online Bill Pay Form PremierBank

Business Online Bill Pay

Customer Information

Company Name(Required)

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone(Required)

Business Phone

Social Security Number(Required)

Date of Birth(Required)

Email(Required)

Confirm Email(Required)

Primary Account Number(Required)

($) Amount of Last Deposit(Required)

Date of Last Deposit(Required)

Online Bill Pay Terms and Conditions

I AUTHORIZE PremierBank to post payment transactions generated from the PremierBank Bill Payment Service to the account indicated on the form being sent electronically. I understand that I am in full control of my account. If at any time I decide to discontinue service, I will provide written notification to PremierBank. My use of the PremierBank Bill Payment Service signifies that I have read the terms and conditions of this Business Online Bill Pay Agreement which have been provided to me electronically by the financial institution. I UNDERSTAND that I am responsible for any loss or penalty ($) that I may incur due to the lack of sufficient funds or other conditions that may prevent the withdrawal of funds from my account. DISCLOSURE TO BUSINESS BILL PAY USERS: Your first three months are absolutely free. After that you will be charged $2.95 per month plus 35 cents per bill paid. The charges will be automatically deducted from your checking account.

Agreement(Required)

Yes, I agree to the Terms and Conditions.

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