Transcription of EFT AUTHORIZATION FORM
1 Reset form Your bank/ABA number will always be 9 digits and will begin and end with these marks |: Account Holder Name: _____. (if different than Insured). DATE YOU WISH TO HAVE PREMIUM PAYMENTS DEDUCTED FROM YOUR ACCOUNT: (PLEASE CIRCLE ONE). EFT AUTHORIZATION form . 1 2 3 4 5 6 7 8 9 10 11 EFT AUTHORIZATION form . EFT AUTHORIZATION form . 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28. Insured Name: _____ Policy # _____. Insured Insured Name: Name: _____. (last name) EFT AUTHORIZATION . _____ (first name) AGREEMENT Policy Policy # # _____.
2 _____. (last name) (first name). I authorize and request the (last Commerce name). Insurance Company (first (Commerce) name). to debit my bank account as payments on this policy or its replacement Agent Code: ____ ____ ____. T 7 X Policy Effective Date: ____/____/____. become due. If a debit is dishonored, the bank will not have any liability, even if the dishonored payment causes the cancellation of my insurance Agent Agent policy. Code: Code: I will ____. ____. be charged ____. the ____. ____. ____. applicable return transaction fee when payments are dishonored.
3 Policy Policy Effective This Effective Date: authority is toDate: ____/____/____. remain____/____/____. in full force until I have Mailing Address: Mailing chosen to Address: remove my policy from the EFT Bill Plan through the CommerceCares System or until Commerce has received written notice from SM. Mailing me Address:in such time and manner as to afford Commerce a reasonable time to act upon it. I may not designate the account of my _____. of its termination, _____. agent, broker, or assigned risk producer for premium withdrawals.
4 Commerce reserves the right to deny or cancel my enrollment in the EFT Bill _____. Plan or deny the bank account I designate for withdrawals. By signing this AUTHORIZATION , I acknowledge that I have read and agree to the _____. _____. conditions set forth in this agreement. Mail this completed form and a VOIDED CHECK, along with your current payment and the payment stub _____. from your bill. If debits will be to a savings account, no voided check is required. _____. TELEPHONE #: (_____)-_____-_____. _____ _____.
5 TELEPHONE. TELEPHONE. **Please provide #: us with (_____)-_____-_____. #: ofyour Signature (_____)-_____-_____. Account Holder daytime telephone number (If different so that we may reach you to verify information. Commerce will not give outDate than insured) your telephone **Please number toprovide us parties. any third with your daytime telephone number so that we may reach you to verify information. Commerce will not give out your telephone **Please provide us with your daytime telephone number so that we may reach you to verify information.
6 _____ Commerce will not give out your telephone _____. number to any third parties. Monthly deductions to be taken from: number to any third Insuredparties. Signature Checking Account n Statement Savings n DateAccount Monthly Monthly deductions deductions to to be be taken taken from: from: n Checking Account nAStatement n Savings Account n YOU. Bank MUST ATTACH A VOIDED IF Checking CHECKn Account DEDUCTIONS ARE FROM Statement CHECKINGS avings Account ACCOUNT. Name:_____. Bank Name:_____. THE INFORMATION IN THIS BOX IS FOR AGENT/COMPANY USE ONLY.
7 Bank Name:_____. PLEASE BE CERTAIN Bank TOTransit ATTACH/ ABA#THIS form TO THE FRONT OF APPLICATION BankOR Account Number PAGE. DECLARATION. Bank Transit / ABA# Bank Bank Account Account Number n NEW BUSINESS EFT Bank (Down Transit payment /ofABA#. 8% must be submitted with application) Number n RENEWAL/BOOK TRANSFER EFT (Submitted 45 days prior to policy effective date). Your bank/ABA number will always be 9 digits and will begin and end with these marks |: n MID TERM TRANSFER (Current policy from Direct Bill to EFT for policies effective 1/1/99 or after).
8 Your bank/ABA number will always be 9 digits and will begin and end with these marks |: Your n NEW bank/ABA. BANK number will always INFORMATION be existing (For 9 digits and EFTwill begin and end with these marks |: policy). Account Holder Name: _____. Account n (if NEW. different Account Holder DEDUCTION. than Name: Name:TO_____. Insured). Holder DATE (For existing EFT policy). _____. (if ndifferent CONVERT than Insured). EFT POLICY DIRECT BILL PREMIUM. STANDARDPAYMENTS. PAYMENT PLAN. (if different DATE. than Insured) YOU WISH TO HAVE DEDUCTED FROM YOUR ACCOUNT: DATE YOU WISH TO HAVE PREMIUM PAYMENTS DEDUCTED FROM YOUR.
9 N CONVERT EFT POLICY. DATE YOU TO DIRECT. WISH (PLEASE. BILL PREMIUM. TO HAVE EZ3 PAYMENT CIRCLE ONE). PLAN (Homeowner PAYMENTS DEDUCTED policies FROM YOUR ACCOUNT: only) ACCOUNT: (PLEASE CIRCLE ONE). 1 2 3 4 5 6 7 8 9 10 11 12 13 (PLEASE. 14 15 CIRCLE. 16 17 ONE) 18 19 Company/Agt. 20 21 22 23 24 25 26 27 28. CIC-1053(06/10). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19. 19 20 21 22 23 24. 20 21 22 23. 1 2 3 4115 Gore 6 7 Road, 8 9 Webster, 10 11 MA 12 01570. 13 14| 508-949-1500. 15 16 17 18| 24 25 25 2626 27 27 2828.
10 EFT AUTHORIZATION AGREEMENT. EFT. I authorize and request the Commerce Insurance EFT. AUTHORIZATION AGREEMENT. AUTHORIZATION . Company AGREEMENT. (Commerce) to debit my bank account as payments on this policy or its replacement Ibecome authorize and due. If arequest debit isthe Commercethe dishonored, Insurance bank willCompany (Commerce). not have any to debit liability, even my if the bank account dishonored as payments payment causes theon this policy orof cancellation itsmy replacement insurance I authorize and request the Commerce Insurance Company (Commerce) to debit my bank account as payments on this policy or its replacement become policy.
