2003 Electronic Funds Transfer Authorization Form printable pdf download

EFT AUTHORIZATION FORM

Insured Name:______________________________________ Policy #______________________

(last name)

(first name)

Agent Code: __ __ __

Policy Effective Date: __/__/__

Mailing Address:

_______________________________________________________________________________

TELEPHONE #: (________)-__________-___________

**Please provide us with your daytime telephone number so that we may reach you to verify information. Commerce will not give out your telephone

number to any third parties.

Monthly deductions to be taken from:

Checking Account

Statement Savings Account

Bank Name:______________________________________________________________________

Bank Transit / ABA#

Bank Account Number

Your bank/ABA number will always be 9 digits and will begin and end with these marks

Account Holder Name:______________________________________________________________

(If different than Insured)

DATE YOU WISH TO HAVE PREMIUM PAYMENTS DEDUCTED FROM YOUR ACCOUNT:

(PLEASE CIRCLE ONE)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

EFT AGREEMENT

I authorize and request the Commerce Insurance Company to debit my bank account as payments on this policy or its

replacement become due. If a debit is dishonored, the bank will not have any liability, even if the dishonored payment causes

the cancellation of my insurance policy. I will be charged the applicable return transaction fee when payments are

dishonored. This authority is to remain in full force until Commerce Insurance Company and the bank have each received

written notice from me of its termination, in such time and manner as to afford Commerce Insurance Company and the bank a

reasonable time to act upon it. You may not designate the account of your agent, broker, or exclusive representative

producer for premium withdrawals. Commerce reserves the right to disapprove the bank account you use for withdrawals.

By signing this authorization, I acknowledge that I have read and agree to the conditions set forth in this agreement.

___________________________________

_______________________

Signature of Account Holder

Date

(If different than Insured)

_______________________________________

___________________________

Insured Signature

Date

YOU MUST ATTACH A VOIDED CHECK IF DEDUCTIONS ARE FROM A CHECKING ACCOUNT.

THE INFORMATION IN THIS BOX IS FOR AGENT/COMPANY USE ONLY

PLEASE BE CERTAIN TO ATTACH THIS FORM TO THE FRONT OF APPLICATION OR DECLARATION PAGE

NEW BUSINESS EFT

(Down Payment of 12% must be submitted with application)

RENEWAL/BOOK TRANSFER EFT

(Submitted 45 days prior to policy effective date)

MID TERM TRANSFER

(Current policy from Direct Bill to EFT for policies effective 1/1/99 or after)

NEW BANK INFORMATION

(For existing EFT policy)

NEW DEDUCTION DATE

(For existing EFT policy)

CONVERT EFT POLICY TO DIRECT BILL 10 PAYMENT PLAN

Company/Agt. Rep._____________________

CIC-1053

Rev. /11/18/03

2003 Electronic Funds Transfer Authorization Form

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