Common Contracts
1 similar Authorization Agreement for Electronic Funds Transfer (Eft) contracts
Authorization Agreement for Electronic Funds Transfer (EFT)Authorization Agreement for Electronic Funds Transfer (Eft) • March 14th, 2018
Effective Date of Change: Named Insured: Account Number: Bank Information Name and Address of Bank: Type of Account: (Checking or Savings) Bank Account Number: Routing Number: (9 digit number between the two colons on the bottom of your check) Name as it appears on your bank account: Payment Plan: (Full Pay, 4 Pay, 9 Pay, 12 Pay) The day of the month you wish to have funds withdrawn: (1st through 28th) _ Terms of Agreement I hereby request and authorize MMG Insurance to debit/credit my bank account as payments for my policies become due. I agree that if a debit/credit is dishonored, the bank shall have no liability if the dishonored debit/credit results in the forfeiture of insurance. This authorization is to remain in full force until MMG Insurance and the above named bank have written notice from me of its termination. No payment to MMG Insurance shall be deemed to have been made unless and until MMG Insurance receives actual credit. Signature of Bank Account Holder: Date
