Utica First Insurance Ez-Pay Eft Authorization Form

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Utica First Insurance EZ-Pay
EFT Authorization Form
!
Insured Name________________________________________________________
Address_____________________________________________________________
Phone Number________________________________________________________
!
NEW BUSINESS – Form must be submitted with application and 15% deposit.
!
EXISTING POLICY- After submitting completed form, please, continue to pay your policy as
billed until notified that the change has been processed. Authorization form must be received one
month prior to the first payment to be withdrawn.
!
All EFT payments will be processed monthly on the effective day of the policy (ie: policy
effective 10/8/13, payments will be processed on the 8
th
of each month). If the withdraw day falls
on a non-business day, the payment will be withdrawn on the next business day.
!
The insured will be notified when payments are to begin and if the withdraw amount changes by
more than $5.
!
Please complete the requested information AND include a voided check for quick and accurate
processing. Thank you.
!
!
Policy # (if assigned)___________________________________________
!
Policy # (if assigned)___________________________________________
!
Account Name________________________________________________
!
Bank Name___________________________________________________
!
Bank Routing #_______________________________________________
!
Account #____________________________________________________
By completing this form, providing a voided check, and signing below, I am authorizing
Utica First Insurance Company to initiate monthly deductions from my bank account
identified on the enclosed check to pay for the insurance policy(ies) and any renewals
thereof, and to deposit any credits/refunds into that account. This authority will remain in
effect until I notify you in writing to cancel it.
!
Signature____________________________________
!
Date________________________________________
Please mail, email, or fax this form along with a voided check to one of the following.
Mail to:
Email to:
Fax to:
Utica First Insurance Company
315-736-1836
P.O. Box 851
Utica, NY 13503-0851

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