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RAF
Acks
Attorneys
Cases
Codes
Dashboard
Filers
Forms
Intake
Payment Change
Login
Messages
Pickup
RAF
PAYMENT CHANGE REQUEST
Date of Request
(Required)
MM slash DD slash YYYY
Check Date
(Required)
MM slash DD slash YYYY
MGA if applicable
(Required)
MGA Code
(Required)
Check Number
(Required)
Agency Name
(Required)
Agency Code
(Required)
Check Amount
(Required)
Agent Name
(Required)
Payee
(Required)
Claim Number if applicable
(Required)
Defendant
(Required)
Power Numbers
(Required)
Check Upload
Check Upload
(Required)
Accepted file types: pg, gif, png, pdf, Max. file size: 10 MB.
REASON FOR CHANGE TO PAYMENT REQUEST
REASON FOR CHANGE TO PAYMENT REQUEST
Void Check
Check Recut
Stop Payment
IF VOID CHECK IN REASON ABOVE
RAF
Agent Name_2
Agent Code2
MGA RAF
MGA Name
MGA Code_2
AR
IF CHECK RECUT IN REASON ABOVE (attach Original Payment Request with form)
Original CK Date
MM slash DD slash YYYY
Original CK
Payee_2
IF STOP PAYMENT IN REASON ABOVE
Check Recut Reason
Agent Lost
UPS Lost
UPS Tracking
For Claims Processing For Accounting Processing
Date Voided in Palmetto Portal
MM slash DD slash YYYY
QB VOID CK JE
Return RAF
Note ORIG INV
Bank BUF
Issue CM VOID INV
QB CORP Write
Apply CM to INV
QB CORP Apply
Claims Spreadsheet
RAF System
Administrator Signature
Management Signature
Accounting Signature
Date
MM slash DD slash YYYY
Date_2
MM slash DD slash YYYY
Date_3
MM slash DD slash YYYY
