Authorization Form For Electronic Funds Transfer
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325 Eastlake Avenue East
PO Box 778
Seattle, WA 98111-0778
E
-P
Plan for automatic monthly premium payments by electronic funds transfer (EFT)
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Save yourself time and postage! If you select our E
-P
Plan, PEMCO Mutual Insurance Company (PEMCO) will
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automatically deduct payments from your bank account. We’ll set up your account and send you a confirmation
showing the amount and dates of your monthly deductions.
Authorization for Electronic Funds Transfer (EFT)
1. By completing this form, I understand that I’m signing up for E
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. I authorize PEMCO to make electronic
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withdrawals (EFT) from my bank account each month to pay my insurance premium. I can terminate this EFT
authorization and choose another payment option at any time by calling PEMCO or by writing to PEMCO at
PO Box 778, Seattle, WA 98111.
2. By enrolling in the E
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automatic monthly premium payments program, I authorize PEMCO to withdraw
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my insurance payment each month via EFT from the financial institution account I specify. Please deduct
payments on the ____ day of each month; if this day falls on a weekend or holiday, deduct my payment on the
following business day.
3. If my financial institution returns an EFT payment unpaid, PEMCO can charge me a reasonable insufficient
funds fee.
4. Before my first EFT payment, PEMCO will tell me in writing the EFT’s start date and the amount of the monthly
deduction. I’ll review for accuracy and tell PEMCO right away if I find any errors or changes. I’m responsible
for making all payments on time up to the initial EFT.
5. If I want to end EFT service, I’ll notify PEMCO at least six (6) days in advance of my next scheduled payment. I
understand that I’m responsible to make all insurance payments on time following EFT cancellation.
6. I understand that PEMCO can terminate this agreement at any time and stop withdrawing my payments
electronically. If it does, PEMCO will give me at least 10 days’ written notice before my next payment is due.
7. I authorize PEMCO to take EFT payments from my account (listed below or as shown on the voided check or
bank verification) on the date shown above or on the next business day if my payment falls on a weekend
or holiday. This authorization will continue until I ask PEMCO to cancel my E
-P
Plan.
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Named insured _________________________________________________________
PEMCO Policy number ___________________________________________________
Routing # ____________________________ Account # ________________________
Signature _________________________________ Date ________________________
I attest that I am authorized to sign checks drawn on the bank account listed or the enclosed canceled/voided check.
Please mail or fax the form, along with a canceled/voided check,
or bank documentation or verification for savings accounts.
PEMCO Payment Center
PO Box 91026
Seattle, WA 98111-9126
PEMCO Customers please fax to:
206-664-2815 or 844-551-8709
PEMCO Agents fax completed forms to:
206-664-2832 or 800-866-9937
Attach voided check for checking accounts, or bank
documentation or verification for savings accounts.
Thank you for using E
-P
.
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1-800-GO-PEMCO (1-800-467-3626)
PEMCO Mutual Insurance Company
Page 1 of 1
10090.002 Rev. 03/2017
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