Payment Details

Please let us know how you intend to make payment.

Name Title First Last Suffix
Service for which you are making a payment Professional Negligence Claim £1169.13 (£995.00+VAT) Other
Other service
If other service specify the amount you are paying £ . Pounds Pence
Payment Method * I will post a cheque payable to Financial Claims Centre I am providing my credit/debit card details below Please provide bank details so that I can deposit the fee myself
Card Type (if applicable) Visa Mastercard Maestro/Switch American Express
Credit/Debit Card Number *

Please enter the long number from your credit/debit card here
For security reasons we will telephone you for the expiry date and 3 digit security code
I authorise you to charge the fee selected to my credit/debit card or that I will make the arrangements specified.

I confirm that I have read and understood the terms and conditions of the requested service as detailed on this site.

Please type your name here *

by typing your name here you are authorising the charge to your credit card

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