Uninsured Employers

Thank you for choosing to pay for your service with the Board’s online payment option. This form is for paying for your duplicate certificate, license verification, business entity and penalty fees.

Fields marked with an asterisk* are required and must be completed prior to clicking Pay Now.

Please enter applicant details as requested below:

First Name

Last Name

Organization

Email

@

Phone Number

#

Address

City/Town

State/Province

ZIP/Postal Code

Do you have your invoice number?

Yes

No

Invoice Number

#

Claim Number

#

Claimant First Name

Claimant Last Name

Amount

$