Payment for Missed Payroll Deductions

Getting Started

In order to make a payment through this system, you (the insured) must be able to provide the following information:
1. Your payroll deduction amount.
2. The number of pay periods you missed.
3. Your full name
4. The last four digits of your social security number.

Customer Information

Your information is used solely to match your payment to our files. We do not sell your information to any third party.

Service Fee

Total Benefit Systems, Inc charges a fee for credit card transactions. This fee is calculated and included in the final payment amount.

Payment Terms

Payments made on this system are for missed payroll deductions. Payments will be processed and remitted to your insurance company(ies) on your behalf, just as if they were taken direct from your payroll.

Refunds

If, by any chance, you have overpaid your policy(ies), refunds would be issued by your insurance company(ies).

First Name *

Last Name *

Last 4 SSN *

Address *

Address2

City *

Zip *

State *

Country *

Phone *

Email *

Deduction Amount *

Missed Pay Periods *

Comment

Total Deduction Amount

Payment method

Clover Hosted Checkout

Billing Zipcode*

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*