Electronic Funds Transfer printable pdf download

ELECTRONIC FUNDS TRANSFER AUTHORIZATION

Electronic Funds Transfer

The Electronic Funds Transfer (EFT) payment plan offers you the convenience of having your insurance premium

payments automatically deducted from your checking or savings account.

The Electronic Funds Transfer Payment Plan Offers Many Benefits…

 No checks to write

 Easy to enroll

 No stamps to buy

 Your information is kept private and secure

 Payment is always on time / avoid late charges

 Choose a payment date convenient to you

 Service charge savings compared to direct bill

Here is How the Electronic Funds Transfer payment Plan Works…

With EFT, your bank account will be debited once per month if you select “monthly”* or once per policy term if you select

“pay in full”**. We will send you a notice before we make the first deduction from your bank account. We will also

send you advanced notification if the amount to be deducted changes. Note that this is a recurring authorization and will

continue for future policy terms unless and until you provide Travelers with notice of cancellation.

Monthly deductions will include premium payments and applicable service charges. In most states, the service charge for the monthly EFT payment

plan is $1.00 per installment. Please refer to the Important Notice about Billing Options and Disclosures provided to you in your policy package for a

listing of all of your billing options and applicable charges.

** Please note that your bank account will be debited once per policy term unless you make changes to your policy that causes an increase in your

premium. We will debit your bank account for those charges after providing you with advanced notification.

Customer Name

2001-91

Three Ways To Complete Your Enrollment:

Customer Address

DATE __________________

Check Example

1. Visit us at amp.travelers.com!

Pay to the

2. Mail the completed authorization form to:

Order of _________________________________ $ ______________

TRAVELERS, One Tower Square

Document management – 2CR, Hartford CT – 06183

_______________________________________________ DOLLARS

3. Fax the completed authorization form to

For: __________________ _________________________________

Document Management Service at 860-277-1035

{0155 0045678}

{123456789}

{0214}

Bank Routing Number

Bank Account Number

Check Number

DETACH AT PERFORATION

Authorization Agreement for Travelers Electronic Funds Transfer Payment Plan

Name:

______________________________________________________

Policy Number:

_________________________

Address:

______________________________________________________

Policy Number:

_________________________

______________________________________________________

Policy Number:

_________________________

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Select payment Frequency:  Monthly  Pay In Full

Indicate Day of Month: (1

only) to Make Payment: ______

 Checking

 Savings

Bank Routing #: ____________________ Bank Account #: ____________________

I authorize The Travelers Indemnity Company and its property casualty affiliates (“Travelers”) to enroll me in the Electronic Funds Transfer Payment

Plan. I understand that this authorization allows Travelers to electronically debit the account I have provided for all policy premium and charges, and if

necessary credit the account. I understand that this is a recurring authorization and it applies to future policy renewals, reinstated policies and

replacement policies and to policies I subsequently enroll. In the event of a deduction amount or a policy number change, or if policies are added,

Travelers will provide advance notice. The advance notice will identify these changes and be sent prior to the scheduled deduction to which the change

applies. I understand this authorization will remain valid until I provide Travelers with notice of cancellation. I also understand that Travelers and/or my

financial institution can cancel my enrollment at any time. I represent that I am the owner and/or authorized signer on the account.

___________________________________________________________

___________________________________

Signature (must be a person authorized to sign on this account)

Date

When your signed agreement is received, we will mail you a notice showing a schedule of your future deductions, including the

amounts and dates when your payments will be deducted. Please continue to make your payment until you receive the notice.

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