PAI : Who We Are : Insurance for Staff

Employee Portion of Insurance Payment

Please use this form to make payments for the employee-paid portion of insurance premiums.

Employee Name

First Name

Last Name

k7nypx0r25w2

Your E-mail

Payment Amount

Select a Payment Method

Credit Card
Bank Account

Cardholder Name

Credit Card #

Visa MasterCard American Express Discover

Expiration Date

Security Code

Billing Zip Code

Account Holder

First Name

Last Name

Account Type

Checking
Savings

Account Number

Routing Number

Your payment will be

Who We Are

Programs

PAI is a day program offering an array of services and opportunities for adults who want to design a life they love.
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Events

Special events help us connect with the community, strengthen relationships and raise money to support programs for amazing people. Join us at our next event and see how you can get involved.
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Volunteer

Volunteers make PAI's programming better! You'll be surprised at what a huge difference a little bit of your time can make.
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