AUTHORIZATION AGREEMENT FOR DIRECT …

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AUTHORIZATIONDateAccount Holder SignatureAccount Holder Name (please print)ACCOUNT HOLDER INFORMATIONAccount/Loan NumberAccount Holder AddressCityStateZipAccount Holder NameAccount Holder PhoneAccount Holder DBA (if business account)Contact Name (if different from above)Contact PhoneRelationshipAUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)21820 Burbank Boulevard, Suite 300Woodland Hills, CA 91367 FAX: (888) 789-0103TEL: (888) 875-4000BUSINESS AUTHORIZED TO DEBIT/CREDIT ACCOUNTAuthorized Business NameAuthorized Business AddressBest Choice Premium Finance (hereinafter called COMPANY)21820 Burbank Blvd., #300, Woodland Hills, CA 91367ACCOUNT HOLDER S BANK ACCOUNT INFORMATIONBank NameBank Account TypeHow to find your Routing and Account Numbers on your check:Bank Routing CodeBank Account NumberBank Routing Number (9 digits)Bank Account NumberBranch CityStateZip 123456789 1234567890123 Personal CheckingSavings

AUTHORIZATION Date Account Holder Signature Account Holder Name (please print) ACCOUNT HOLDER INFORMATION Account/Loan Number …

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