Authorization Agreement For Preauthorized Payments (Ach Debits) - New Hampshire Insurance Department

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NEW HAMPSHIRE INSURANCE DEPARTMENT
ACH DEBIT authorization for payment of Premium Taxes
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS (ACH DEBITS)
ORGANIZATION NAME: State of New Hampshire Treasury
ORGANIZATION ID NUMBER: Insurance Dept.
I (we) hereby authorize The State of New Hampshire Treasury, hereinafter called STATE, to
initiate debit entries and to my (our) Checking (
) Savings (
) account indicated below at
the depository named below, hereinafter called DEPOSITORY, to debit the same to such
account.
DEPOSITORY
NAME _________________________________ BRANCH__________________________
CITY __________________________________ STATE _________ ZIP ______________
ROUTING NUMBER _____________________ ACCOUNT NO. ____________________
This authority is for payment of the Premium Tax obligation for:
COMPANY
COMPANY
NAME __________________________________ NAIC Code _____________
This authorization is to remain in full force and effect until the STATE has received written
notice from me (or either of us) of its termination in such time and in such manner as to afford
The STATE and DEPOSITORY a reasonable opportunity to act on it.
PRIMARY NAME __________________________TELEPHONE# ____________________
SECONDARY NAME _______________________TELEPHONE#____________________
DATE ___________________________________ SIGNED X _______________________
SIGNED X _______________________
NOTE: All written debit authorizations must provide that the receiver may revoke
the authorization only by notifying the Originator in the manner specified
in the Authorization. The receiver must be given a copy of their written
debit authorizations.

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