Transcription of Electronic Payment Authorization - ExpressIT
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Electronic Payment Authorization - ExpressIT
metlife Auto & HomeElectronic Payment Authorization - ExpressITUse this form to allow recurring monthly Electronic withdrawals from your bank 2: Choose what you would like to doSECTION 3: Policy information(Select all that apply.) SM(GrandProtect , Combo and PAK II have single account numbers.)(List policy number(s) you want to include)(Check policy type for each policy number)SECTION 1: Policyholder informationFirst nameMiddle initialLast namePhone numberStreet addressCityStateZIP Code(Policyholder & Bank Account Owner name must match)(Complete one policy option below) Include your home policy in this authorizationDo not include your home policy(Default, if none selected)RecreationalVehiclePersonal ExcessLiabilityHomeBoatAutoPolicy Number(s)SECTION 4: Electronic Payment bank information(Refer to page 2 for important information)Bank NameBank Routing NumberBank Account NumberCheck the day of the month you would like us to process your payment1stday8thday15thdayDefault,( if none selected)22nddaySECTION 5: Authorization & signatureBank Account Owner's SignatureDateSECTION 6: How to submit this formMail:Fax:Email.
may provide as a replacement, for payment of my premium. Please complete, sign and return form to avoid delays MetLife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates, Warwick, RI. MPC-1098-000-1015 Page 1 2of
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