Transcription of AGENT/BROKER DIRECT DEPOSIT OF PAYMENTS …
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AGENT/BROKER DIRECT DEPOSIT OF PAYMENTS …
Form 732494 10/15 1 of 2 AGENT/BROKER DIRECT DEPOSIT OF PAYMENTS INSTRUCTION SHEET(PLEASE FAX ONLY PAGE 2) foremost Insurance Company Grand Rapids, Michigan, Bristol West Insurance Services of Florida, Inc. and their subsidiaries and affiliates (referred herein as the Company ) can electronically DEPOSIT PAYMENTS ( commissions or other PAYMENTS such as incentive and/or bonus PAYMENTS ) into agents/brokers personal or business account. Agents/Brokers must complete this form to enroll for the first time, to make changes to their depository bank information or to terminate the DIRECT DEPOSIT authorization : This form is strictly for DIRECT DEPOSIT of agent statement. It should not be used to setup any customer / policy holder billing Complete Page 2 by reading the authorization agreement statement, check mark the appropriate boxes in the Type of Action & Product(s) This Applies To sections, and then legibly print & sign your Provide your Producer Code(s) for each line of business (if known).
Form 732494 10/15 1 of 2 AGENT/BROKER DIRECT DEPOSIT OF PAYMENTS INSTRUCTION SHEET (PLEASE FAX ONLY PAGE 2) Foremost Insurance Company Grand Rapids, Michigan, Bristol West Insurance Services of Florida, Inc.
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