Avoid late fees and save money in reduced billing fees by using our Electronic Fund Transfer (EFT) payment method. To sign up for this easy-to-use method of paying your bill, please complete the following information.

* Required

Electronic Funds Withdrawal Authorization

*Policy State:
*Policy Number:
*Named Insured:
*Bank ABA Routing Number:
*Account Number:
*Bank Name:
*EFT Account Holder Name:
*Email Address:
*Indicate type of account to be debited: Checking Savings
*Indicate payment option: Full Payment Monthly
Example of location of ABA Routing Code
(Bank Identification number) and customer
Bank Account Number

Example Bank Check for Electronic Funds Transfer

Please debit my checking or savings payment to (The Company) for insurance
premiums, including fees and subsequent renewals.


I Agree that:


1. The Company does not need to notify me that premiums are due as long as this automatic payment plan is in
effect. In addition, no premium or any portion of a premium will be considered paid unless The Company
receives payment at its Home Office. If my account has insufficient funds on the date of automatic payment
deduction, The Company will attempt a second deduction within a few days. I will pay any charges for the initial
non-payment or second payment. If funds are not available at the second attempt, my account will be removed
from this payment option and direct billed.

2. If the authorization is for a policy with a payment arrangement that is for any payment plan we offer for EFT, this
authorization constitutes approval to change the payment arrangement.

3. It is not necessary for any officer or employee of The Company to sign a debit to my account.

4. The Company will incur no liability if my account has insufficient funds for a payment because of an automatic
deduction.

5. The Electronic Fund Plan will continue unless terminated by The Company or me with thirty (30) days written
notice to either party. In addition, The Company may terminate the plan immediately if any debit is not paid upon
request.


I understand that by typing my name in the box labeled "Name" at the bottom of the authorization screen and clicking the
button marked "Submit", I have created a legally binding signature on this authorization form. This electronic signature is
the equivalent of my handwritten signature. This signature shall be valid evidence of my intent and agreement to be
bound to the Terms and Conditions of this website. I further acknowledge that I am the owner or I am authorized to use
the above account.


Please enter your signature exactly as you have entered it on the Electronic Funds Authorization Form <Account Holder Name>

Name
EFT Account Holder
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