DISCLOSURE: Electronic submission of this form does not mean your payment has been made, it is only a request. Do not assume payment has been made until receipt/confirmation of your payment is emailed to you by our agency. Empire Insurance Agency does not take any responsibility for past due payments, late fees, or cancelled policies that result from this payment form not being processed. If your payment is due within 72 hours of your submission, it is recommended that you contact your carrier directly and do not rely on this payment method. Incomplete or incorrect information entered on this form may result in your payment not being able to be processed.