Establishing secure connection…Loading editor…Preparing document…

Authorization Agreement for Invoice Payments

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

STATE OF CALIFORNIA – DEPARTMENT OF INSURANCE
Electronic Funds Transfer (EFT) Authorization Agreement for Invoice Payments

CDI-177 (Rev. 5/2019)

ACCOUNTING SERVICES BUREAU

ACCOUNTS RECEIVABLE SECTION

CDI ACCOUNTING USE ONLY

Please check appropriate box:

New EFT Co. Authorization Agreement
Change EFT Contact Name/Phone/Email
Withdraw from EFT Payment Program

See reverse for instructions on completing this authorization agreement.

SECTION I – COMPANY INFORMATION

SECTION II – EFT CONTACT PERSON

Person designated to create a user profile and initiate EFT ACH Debit payments to the California Department of Insurance (CDI).

SECTION III – ACH DEBIT PAYMENT METHOD

I understand that once this authorization agreement is approved by the California Department of Insurance (CDI), I will be provided a temporary security code and a company identification number. I am then required to go to First Data’s payment website at www.govone.com/PAYCAL to complete the remaining registration by adding my payment information, which includes bank account number and routing number, before any invoice payments can be initiated by me or the EFT contact person listed above. This authorization agreement is to remain in full force until EFT payments are no longer required or until CDI and I mutually agree to terminate my voluntary participation in the EFT program.

The person named below has authority to approve the use of EFT transactions for the payment of balances due to CDI.

A copy of this agreement will be returned confirming your enrollment along with instructions on how to create a user profile to begin using the EFT system.

SECTION IV

*** For CDI Accounting Use Only ***

Please email the completed form to: e-mail arbilling@insurance.ca.gov

For EFT assistance or questions email or contact us at (916) 492-3242.

Make a copy for your records.

Instructions for Completing the EFT Authorization Agreement for Invoice Payments

General

Please type or print clearly. Check the appropriate box for completing this form. Return the EFT Authorization Agreement to CDI.

Section I

Enter all company information in this section. Company name and company ID number should match the name and number on your invoices. If you will be making payment for multiple companies, a separate agreement form will be required for each. If your organization has been assigned a National Association of Insurance Commissioners (NAIC) number, please provide this number as well.

Section II

Enter the name and contact information for the person designated to create a user profile and initiate EFT ACH Debit payments to CDI.

Section III

Enter the name and contact information of the representative approving the use of ACH Debit Electronic Funds Transfer as a method of payment for your organization.

Section IV

CDI Accounting Use Only.

Important Information

EFT Start Date for New Accounts

You will be notified in writing when your agreement is approved. Your confirmation form will indicate when you may start making EFT payments. Do not attempt to pay by EFT before your approved start date. Until your enrollment is confirmed, please continue to submit timely payments in check form to the address provided on your invoice. All due dates and late charges will be enforced.

Payment Method

ACH Debit is the only payment method available for departmental invoices.

Banking Information

You will enter banking information at the time you create your user profile. CDI will not have access to enter or maintain your banking information.

Withdrawal Information

The EFT invoice payment method is optional. By completing the Authorization Agreement form you are voluntarily participating in the EFT program. If you wish to withdraw from this EFT program, you must submit your request in writing to arbilling@insurance.ca.gov. Please note the Department will need at least two weeks prior notice in order to cancel this authorization agreement.

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the Authorization Agreement for Invoice Payments Is

The Authorization Agreement for Invoice Payments is a written or electronic contract that gives a payee permission to collect payments from a payer to satisfy invoices. It identifies the parties, payment method (for example ACH or card-on-file), invoice delivery and frequency, permitted amounts, dispute procedures, and revocation terms. The agreement documents the payer's consent to automated or on-demand debits, records authorization for reconciliation and audit purposes, and establishes notice and cancellation processes to reduce collection disputes.

Why a Clear Authorization Agreement Matters

A formal authorization streamlines collections, reduces late payments, and creates an auditable record for accounting and compliance. Clear terms for timing, method, and disputes lower administrative burden and improve cash flow predictability.

Why a Clear Authorization Agreement Matters

Who Typically Completes This Agreement

Accounts receivable, billing managers, vendors, and finance teams use this agreement to automate invoice collections and record payer consent.

  • Small and mid-size businesses automating recurring customer invoices to reduce manual billing and accelerate cash flow.
  • Large enterprises managing high-volume vendor billing and reconciliations with ACH debits, credit card on file, or virtual cards.
  • Professional services, utilities, and subscription platforms collecting recurring fees, late charges, and agreed adjustments from customers.

Choosing the right internal owner and documented account details reduces disputes and helps ensure enforceability across payment channels.

Core Elements a Professional Agreement Should Contain

A professional Authorization Agreement for Invoice Payments organizes scope, payment method, limits, invoicing detail, dispute handling, and termination clauses to reduce ambiguity and support compliance.

Authorization Scope

Specify whether the authorization covers one-time invoices, recurring scheduled invoices, or both; include start and end dates, specific invoice identifiers, and any conditional triggers permitting automated collection.

Payment Method

Identify accepted channels (ACH debit, credit/debit card, virtual card), provide account or token details, specify processor and settlement terms, and note authorization for processing fees or adjustments.

Amount Limits

State single-transaction and aggregate monthly limits, maximum allowable variances from invoice amount for fees or rounding, and any thresholds that require manual approval.

Invoice Terms

Detail invoice frequency, due dates, late fees, notice procedures, acceptable invoice formats, and the contact method for invoice delivery and formal dispute submission.

Dispute Process

Describe steps for disputing charges, timelines for submitting claims, withholding rights during disputes, required supporting documentation, and how adjustments are applied after resolution.

Revocation Rights

Explain how a payer revokes authorization, required notice periods, steps for stopping future debits, and the effect on outstanding and disputed balances.

Step-by-Step: From Draft to Active Authorization

Follow these steps to prepare, sign, and activate an authorization agreement for invoice payments.

  • 01
    Prepare Document: Draft terms: scope, amounts, method, dispute process.
  • 02
    Obtain Consent: Present ESIGN consumer disclosure if consumer-facing and capture assent.
  • 03
    Verify Account: Confirm account ownership via micro-deposit or tokenized verification.
  • 04
    Activate: Enable automated collection and record the first scheduled payment.

Configuring an Online Collection Workflow

Configure settings that control how invoices are routed, authenticated, and captured when going live.

Field Configuration
Notification Settings Auto-send invoice and payment reminders to payer email or SMS.
Authentication Level Choose email link, SMS code, or KBA depending on risk profile.
Retry Logic Set retry attempts for failed debits and fee application rules.
Record Retention Enable export of signed PDFs and audit trail for storage.

How Signed Authorizations Are Processed

After execution, the agreement routes through billing, payment processor, and accounting for reconciliation.

  • Send to Payer: Distribute via secure link or email for signature.
  • Authenticate: Signer completes authentication chosen in workflow settings.
  • Record Signature: System captures timestamp, IP, and audit trail entry.
  • Enable Payments: Processor receives authorization token and schedules debits.

Technical and Integration Considerations

Select a platform that supports necessary authentication methods, document formats, and integrations with accounting or ERP systems.

  • Integrations: Salesforce, NetSuite, Google Workspace, and common ERPs supported.
  • File Formats: PDF, DOCX, HTML, and Excel inputs and signed outputs.
  • Authentication: Email link, SMS code, KBA, SSO, and MFA options.

eSignature Vendor Pricing Snapshot

Compare common pricing and basic compliance features across vendors to evaluate platform suitability for authorization workflows.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Security and Compliance Essentials

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest
Access Controls: Role-based access, SSO, and MFA available
Audit Trail: Full timestamped audit trail and logs
BAA Available: HIPAA BAA available upon request
Authentication: Email, SMS code, KBA, and 2FA options
Certifications: SOC 2 Type II; ISO 27001; PCI DSS

Penalties and Risks to Watch For

Insufficient Authorization: Payments returned; collection claims denied
Unauthorized Debits: Bank reversal and reputation risk
Chargebacks: Processing fees and delayed cash flow
Regulatory Fines: State consumer protection penalties possible
Backup Withholding: 24% withheld if TIN missing
Data Breach: Notification obligations and legal exposure

Common Preparation Mistakes to Avoid

  • Using vague authorization language that fails to specify payment method, frequency, or maximum amounts leads to disputes and returned payments.
  • Collecting account details without secure transmission or failing to confirm account ownership increases fraud risk and causes bank return charges.
  • Omitting required ESIGN consumer disclosures for consumer-facing authorizations can undermine electronic consent under federal rules.
  • Not defining dispute timelines and evidence requirements often prolongs resolution and causes withholding of payments during investigations.

Key Timing Rules and Typical Deadlines

Set clear dates for effectiveness, first debit, revocation notice, and dispute windows to avoid operational confusion.

Effective Date:

Date authorization begins (MM/DD/YYYY).

First Payment Date:

Specify the first scheduled debit date.

Revocation Notice:

Specify required notice period to stop future debits.

Bank Return Window:

Allow time for bank processing and return handling.

Dispute Window:

Define timeline for submitting charge disputes and evidence.

Milestones from Agreement to Ongoing Collections

Track milestones to ensure the authorization is valid, executed, and integrated into payment operations.

01

Draft Finalization

Agree terms, limits, and dispute procedures before signature.

02

Execution

Signer completes authentication and e-signature or notarized acknowledgement.

03

First Collection

Processor executes the initial debit and confirms settlement.

04

Ongoing Reconciliation

Accounting reconciles invoices, payments, and any returned items regularly.

Frequently Asked Questions About Authorizing Invoice Payments

Answers to common questions about enforceability, revocation, notarization, updating payment details, and dispute handling.


Need help? Contact support

Explore Templates

Probate Attorneys of San Diego Handbook for Probate Executors Patient Registration Form North Carolina Marital Property Agreement with Dependent Minor Child(ren) Affidavit of Domestic Abuse Victim Affidavit and Agreement General or Common Law Affidavit
be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.