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.

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

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