Electronic Funds Transfer (Eft) Authorization Form

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Electronic Funds Transfer (EFT)
Authorization Form
ID No.___________________________________________
(Please make a duplicate copy to retain for your records.)
Name of Primary Insured/Owner ( please print ):
Signature of Primary Insured/Owner:
________________________________________________
________________________________________________
Primary Insured E-mail Address: _________________________________________________________________________
K
K
Please draft on the ______________ of each Month/Quarter.
EFT Options:
Monthly
Quarterly
day
If you have chosen our Quarterly EFT option, you will
In Tennessee and Texas, drafts may only be scheduled on
no longer receive a quarterly billing statement.
1) the premium due date; or 2) up to 10 days after the due date.
PLEASE PRINT
Account Holder Information (Business Accounts are not accepted):
Name: _____________________________________________________________________________________________
Name(s) As Displayed on Check
Address: ___________________________________________________________________________________________
P.O. Boxes are NOT Accepted
City: _______________________________________________ State: ___________________ ZIP: __________________
Phone:_____________________________________________
ACCOUNT HOLDER’S SIGNATURE REQUIRED BELOW
I hereby authorize Golden Rule Insurance Company to initiate debit entries to the account indicated below. I also autho-
rize the named financial institution to debit the same to such account. I agree this authorization will remain in effect until
you actually receive written notification of its termination from me.
Account Holder’s
Signature: _____________________________________________________________________________________
As shown on the account to which this authorization is applicable
Printed Account Holder’s Name: ____________________________________________________________________
Date Signed: _____________________________________
ACCOUNT HOLDER’S INFORMATION — REQUIRED
1. Write your nine -digit check routing number for your financial
institution here:
JJJJJJJJJ
2. Write your checking account number here:
JJJJJJJJJJJJJ
(You can also find your checking account number by looking
on your most recent financial institution statement.)
FINANCIAL INSTITUTION’S INFORMATION — REQUIRED
Name: _____________________________________________________________________________________________
Address: ___________________________________________________________________________________________
City: _______________________________________________ State: ___________________ ZIP: __________________
Please mail the completed form to: Golden Rule, 712 Eleventh Street, Lawrenceville, IL 62439-2395 or Fax to 618-943-3136
790-1206
Dec 27 2006 07:43:35 am

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