Bank Account Verification Form

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Bank Account Verification Form
Section A. Must be completed by applicant
Name (Last, First, Middle Initial)
Ref #:
I authorize you to release the following information requested by Progressive, concerning my
bank account with your bank
Yes
No
Signature
Date:
Section B. Must be completed by bank representative
Financial Institution Name (if credit union please include the member number)
Bank Address
State
Zip
Routing Number (9 digits)
Account Number
Has this account been open
Does this account accept
Type of Account
three months?
ACH debits?
Yes
No
Yes
No
Checking
Savings
Does the applicant have direct deposit into this account?
Yes
No
Bank Representative Signature
Phone Number
(____) _____-________ ext. ____
Bank Representative Name (Print)
Date:
Please fax form to Progressive: 1-877-966-2888
A stamp must be placed in this section to
verify the information on this page.
Toll Free: 877.898.1970
Fax: 877.966.2888
Email:
11629 South 700 East Suite 250, Draper, UT 84020

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