AGENT/BROKER DIRECT DEPOSIT OF PAYMENTS …

1 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).

2 3. Complete the Financial Institution Information section. Attach a voided copy of your pre-printed personal or business check. The check must show the bank name, city, state, zip code, account number and bank routing/transit number. Do not use starter checks. Insurance Agency 1234100 Main StreetAnytown, NY 10012 PAY TO THEORDER OF _____ $_____ DOLLARSFOR _____Routing/Transit Number(9 digits)Account Number4. If imprinted checks are not available, obtain a validation letter from the bank. The letter must be on the bank s letterhead, provide the account name, bank routing/transit number and signed by the bank manager or authorized Fax or mail the completed authorization agreement (page 2 only) along with a voided pre-printed check or bank validation letter.

3 New AGENT/BROKER Set-up Packets Return this form to your Marketing Representative Existing Agents/Brokerso Fax to: 1-616-956-4369o Mail to: foremost Agency Contract ManagementForemost Insurance CompanyPO Box 2128 Grand Rapids, MI 49501-21286. To prevent delays in processing your request, please remember to: Print legibly. Do not attach starter checks or DEPOSIT tickets/slips. These documents do not contain the correct bank information. Do not send page 1 (this page). Please send only the authorization agreement (on page 2). Sign the authorization of 2 Form 732494 10/15 Insurance underwritten by a member of the foremost Insurance Group or the Bristol West Insurance Group. " foremost ", the "F" logo and DistinctChoice are registered trademarks of FCOA, LLC, 5600 Beech Tree Lane, Caledonia, MI 49316.

4 Bristol West Insurance Group and Bristol West are registered trademarks of Bristol West Holdings, Inc., 900 South Pine Island Road, Plantation, FL 33324. The foremost and Bristol West companies are members of the Farmers Insurance Group , 4680 Wilshire Blvd. Los Angeles, CA of Action: Enroll (New DIRECT Change Bank Account Te r m i n a t eDeposit Enrollment)Product(s) this applies to: Auto Specialty Lines Business Insurance(Please provide Producer Codenumber(s) if known / applicable) foremost Auto Producer CodeForemost Specialty Lines Producer CodeBusiness Insurance Producer CodeAGENT/ broker DIRECT DEPOSIT OF PAYMENTS AUTHORIZATION AGREEMENTI hereby authorize foremost Insurance Company Grand Rapids, Michigan, Bristol West Insurance Services of Florida, Inc. and their subsidiaries and affiliates ( Company ) to electronically make deposits to the account named on this form in the financial institution indicated below.

5 I hereby authorize the Depository Financial Institution indicated below to accept and post these transactions to my account. I understand that my name must be on the account into which I am depositing funds. It is agreed that these deposits and adjustments may be made electronically and under the Rules and Regulations of the National Automated Clearing House authorization will remain in effect until I provide written notification to the Company of its termination in such time and in such manner as to afford the Company and the Financial Institution reasonable time to act on it. In the event that my Financial Institution or account number changes, I acknowledge that five (5) business days advanced notice must be given to the Company before the changes take effect.(Print Legibly the Name of Authorized Party)(Title)(Signature of Authorized Producer/Bank Account Personnel)(Date)Agency/Brokerage Name _____(Print Legibly)Address _____ City _____ State _____ Zip _____Phone _____ Fax # _____ Email Address _____ Attach Voided Check, orProvide a Verification Letter from the Financial InstitutionAgency / Brokerage Financial InstitutionName of Bank Account Holder _____Bank Name _____Bank City, State, Zip City _____ State _____ Zip _____9-Digit Routing/Transit NumberBank Account Number_____Foremost Agency Contract Management, foremost Insurance CompanyPO Box 2128, Grand Rapids, MI 49501-2128, Fax No.

6 1-616-956-4369 Confidential