Electronic Funds Transfer (Page 2 of 2) in pdf

Keep this copy of the form for your records

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.

Detach and send to:

Travelers

One Tower Square

Document Management – 2CR

Hartford CT 06183