Common Contracts

Electronic Funds Transfer Authorization Form

April 14th, 2017

• Filed
  April 14th, 2017

AAFP Insurance Services, Inc. Automatic Insurance Payment Agreement provides for Electronic Fund Transfer for the purpose of making your insurance payment without the use of a check. Your signed authorization below is required. The electronic debit will occur on each scheduled due date according to your selected mode of payment. If the scheduled transfer occurs on a weekend or bank holiday, your designated account will be charged the next business day. If you choose to use your checking account, enclose a blank voided check for that account. If you choose to use your savings account, you must confirm that your bank permits electronic fund withdrawals from the account and obtain your bank's transit routing number. The amount of the automatic debit may vary due to scheduled increases as the result of age changes, amounts of insurance or a premium rate change. You will be notified at least 45 days in advance of rate changes, for premium contribution changes due to scheduled age or benefit