Frankenmuth Electronic Funds Transfer (Eft) Authorization Form
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1Electronic Funds Transfer (EFT) Authorization Form
I authorize Frankenmuth Insurance to make withdrawals from my account for automatic insurance
premium payments at the financial institution listed below.
Insured’s Name: _________________________________________________________________
Billing Account #(s) _______________________________________________________________
Bank Routing Number: (9 Digits on bottom left of check for personal checks)
__ __ __ __ __ __ __ __ __
To be withdrawn from: (Check one)
□
Checking Account Number: ____________________________________________________
(Enclose a voided check)
□
Savings Account Number: _____________________________________________________
(Enclose a deposit slip)
□
Frequency: (Check one)
One-Time Payment Amount Due $_________________ and/or
□
Recurring payments (Select one below)
□
Monthly:
payment withdrawn on: _______________ (Choose any day between the 1
and 28
)
st
th
□
Quarterly:
payment withdrawn on:
1
: _________ OR 15
__________ (Select One)
st
th:
□
Semi-Annual:
payment withdrawn on: 1
: _________ OR 15
__________ (Select One)
st
th:
□
Annual:
payment withdrawn on:
1
: _________ OR 15
__________ (Select One)
st
th:
Note: May take 30 to 60 days for withdrawal to become effective. Frankenmuth Insurance or I may terminate this
agreement by notice to the other party.
Name: (Please Print) _____________________________ Daytime Phone # _______________
Email Address: ____________________________________________________________________
Signature: ________________________________________________ Date: __________________
Completed Forms may be returned to:
Frankenmuth Mutual Insurance Company
1 Mutual Avenue
Frankenmuth, MI 48787-0001
Fax # 989-652-9222 Email:
FIC-EFT (12/15)
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