AUTHORIZATION AGREEMENT FOR DIRECT PAYMENT (ACH)
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AUTHORIZATION AGREEMENT FOR DIRECT PAYMENT (ACH)
Insured’s Name: SPS Account Number:
Name on Checking Account:
Checking Account Address:
City: State: Zip code:
Phone Number: Email Address:
1. Attach a voided check
2. The number of installments:
3. The amount of each payment is $
4. Select Premium will debit each payment monthly on your due date of . If due date falls on a holiday or weekend, payment will be drafted on the next business day.
5. This authorization is not transferable. A new authorization must be completed for each Select Premium account and renewal.
6. Don’t forget to update your records on a monthly basis.
Cancellation of Direct Payment Plan: Select Premium must be notified in writing within 5 business days of your next due date. Any direct payment returned not honored by your bank will be accessed a $15.00 return debit fee ($20.00 for Arkansas or $25.00 for Oklahoma) and will result in the Direct Payment Plan to be voided immediately!
Processing Fee: A $1.00 processing fee will be automatically added to each monthly installment.
Insured’s Signature:
Print Name: Date:
ATTACH VOIDED CHECK HERE
PLEASE RETURN THIS FORM BY:
FAX (979) 578-8987
OR
EMAIL TO SERVICE@
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