Friends Cove Mutual Insurance Company Direct Debit Payment Agreement printable pdf download

Friends Cove Mutual Insurance Company

Direct Debit Payment Agreement

I (we) hereby authorize Friends Cove Mutual Insurance Company to initiate debit entries to my (our)

checking account at the financial institution listed below, for the collection of premiums on the policy or

policies specified, as well as any new policy which I may acquire subsequent to the date listed.

Insurance Policy #:

Bank Name:

Your Name(s):

Bank Address:

Street:

ABA Routing #:

City:

Bank Account #:

State:

ZIP:

Telephone:

email:

Payment Plan Selection:

Annual

Semi-Annual

Quarterly

10 Pay (ACH Only)

Please include a copy of a VOIDED CHECK with your submission

Your payment will be withdrawn on the closest date to your regular Due Date that our system

will permit. When the set up is complete you will be provided an amortization schedule

showing the dates the payments will be withdrawn.

Signature:__________________________________

Date: ____________________

Signature:__________________________________

Date: ____________________

I understand that this authorization will remain in effect until it is cancelled in writing, which may be done by either party providing thirty (30)

days written notice. Friends Cove Mutual Insurance Company may terminate the direct debit plan immediately by notice if any debits, within

a policy renewal period, are not paid upon execution or presentation. Any debits not honored or that are returned due to Non-sufficient

Funds (NSF) will cause the policy to be cancelled for non-payment of premium. I agree to notify Friends Cove Mutual Insurance Company

in writing of any changes in my account information or termination of this authorization at least 30 days prior to the next billing date. If the

above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business

day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the next

payment is due based upon the payment plan selected above. In the case of an ACH Transaction being rejected for Non Sufficient Funds

(NSF) I understand that Friends Cove Mutual Insurance Company may at its discretion attempt to process the charge again within 30 days,

and agree to an additional $40 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized

recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I

agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization

form.

Friends Cove Mutual Insurance Company Direct Debit Payment Agreement