Automatic Payment Enrollment (ACH)

Authorization for Recurring Premium Payments via Automated Clearing House (ACH)

By signing below, you authorize [Insurance Company Name] (hereinafter referred to as "the Company") to initiate electronic debit entries (withdrawals) from the financial institution account designated below for the payment of your insurance premiums and any related fees, and authorize your financial institution to honor such debits. This authorization is for recurring payments until revoked.

1. Policyholder/Insured Information

	Policyholder Full Name	Policy Number
	A	B
1
2
3

Contact Phone Number:

Email Address:

Billing Address Line 1:

Billing Address Line 2 (Apt/Unit):

City:

State/Province:

Zip/Postal Code:

2. Payment Details

Payment Frequency

Monthly

Quarterly

Semi-Annually

Annually

Scheduled Debit Date: Premiums are typically withdrawn on or around the scheduled date each month (e.g., the 5th, 15th, or due date). If this date is a weekend or bank holiday, the payment will be processed on the next business day.

Debit Amount: The amount debited will be the current premium due for the policy/policies listed above, which may vary upon renewal or due to policy changes. You will receive notice of the amount and date of withdrawal prior to each payment, as required by law.

3. Financial Institution Information

Account Holder Name(s): (Must match the name(s) on the bank account)

Name of Financial Institution:

Transit/Routing Number (ABA):

Account Number:

Account Type:

REQUIRED: Please attach a voided check or deposit slip for the account specified above to ensure accurate data entry.

Choose a file or drop it here

4. Terms and Conditions (ACH Authorization Agreement)

Authorization: This authorization permits the Company to initiate recurring debit entries to the account specified for the purpose of collecting insurance premiums.
Accuracy: I certify that I am the authorized signatory on the bank account listed above and that all information provided is accurate. I understand that incorrect information may result in my payment being returned, which could lead to policy cancellation and/or returned payment fees.
Insufficient Funds (NSF): I understand that if an ACH debit is rejected for Non-Sufficient Funds (NSF) or any other reason, the Company may, at its discretion and in accordance with applicable rules, resubmit the debit. I may also be subject to a returned item fee charged by both the Company and my financial institution.
Changes/Termination: This authorization remains in effect until the Company receives written notification from me of its termination or modification. I agree to notify the Company in writing of any changes to my bank information or a request to stop or terminate this authorization at least [Specify number, e.g., 10 or 15] business days before the next scheduled debit date.
Policy Status: I understand that participating in automatic payments does not alter my obligation to pay premiums by the due date, and that failure of an ACH debit (regardless of the reason) may result in my policy being considered past due and potentially subject to cancellation.

5. Signatures

I have read and agree to the terms and conditions outlined above. I authorize [Insurance Company Name] to begin automatic premium debits from the account specified.

Account Holder Signature:

(If two signatures are required on the bank account, both must sign)

Joint Account Holder Signature:

6. Company Use Only

Date Received:

Processed By:

Effective Date:

ACH Status:

New Enrollment

Change

Cancellation

Verification of Voided Check

Yes

No