Insurance Auto EFT Authorization

INSURANCE AUTO EFT AUTHORIZATION

Applicant / Insured Information

Date of birth:   Policyholder phone:   Email:

Policy Information

Policy number:   Policy type:

Coverage limit (total insured value):   Deductible:   Premium amount to draft:

Policy period: From to

Coverage Selected (select all that apply)

Liability    Collision    Comprehensive    Uninsured Motorist    Medical Payments    Roadside Assistance

Bank Account / EFT Payment Instructions

I authorize the insurer and its agents to initiate debit entries to the account indicated below for payment of premiums, installments, fees, and any adjustments authorized under this authorization.

Account type:    Checking    Savings    Business

Payment Frequency / EFT Options

Monthly    Quarterly    Semi-Annual    Annual    One-time draft

Draft date preference each period (day of month):   If no preference, the insurer may select a draft date consistent with billing cycle.

Beneficiary / Refund Payee (for premium refunds or credits)

Relationship:   Allocation percentage:

Exclusions and Limitations

This authorization is limited to electronic debits initiated by the insurer for amounts expressly permitted under the insurance policy and related billing schedules. The insurer is not liable for delays or failures in transmission caused by the bank, clearinghouse, or other third parties. The insurer will not initiate debits for amounts other than premiums, fees, or adjustments related to the covered policy without prior written notice to the policyholder describing the reason for the adjustment and the amount to be debited.

The policyholder remains responsible for any insufficient funds, returned item fees, or penalties assessed by the financial institution. Repeated non-sufficient funds occurrences may be grounds for suspension of EFT privileges or policy cancellation in accordance with the policy terms.

Acknowledgement, Authorization and Certification

By signing below, I certify that I am either the named account holder or an authorized signer on the bank account identified above. I authorize the insurer to initiate debit entries and, if necessary, credit entries to correct erroneous debits. This authorization will remain in effect until the insurer receives a written cancellation from me and has had a reasonable time (not less than thirty days) to act on it. I understand that changes to premium amounts resulting from endorsements, renewals, audits or other adjustments may change the amount debited and that I will receive notice of material premium changes as required by the policy.

I waive any right to prior notice of each debit entry except as required by the policy or law. I agree to notify the insurer immediately of any changes to the account information provided herein. I understand that termination of this authorization does not relieve me of amounts owed for premiums earned or owed to the insurer prior to cancellation.

Consent to Electronic Presentment

By executing this authorization I consent to electronic presentment of debits to the account designated above. I understand that this consent constitutes my express agreement for the insurer to present charges electronically and for my financial institution to honor such electronic transactions consistent with applicable law.

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