AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS
Logic AUTHORIZATION AGREEMENT TO WITHDRAW FUNDS HMH
(ACH DEBITS)
(Check All that Apply)
( LOGIC UNDERWRITERS CLIENT NAME: _____________________ ( HMH PREMIUM FINANCE POLICY/ACCT NO: __________________
( LOGIC INSURANCE SERVICES CLIENT NO: ________________________
I (we) hereby authorize the checked company, to initiate a debit entry or entries to my/our account indicated below at the depository financial institution named below, hereinafter called THE BANK, and to debit the same to such account.
BANK
NAME_________________________________________________________________STATE_______________
ACCOUNT HOLDER(s) NAME____________________________________ PHONE NO.___________________ (Please Print)
ROUTING NUMBER ACCOUNT NO.
PAYMENT DEDUCTION: (Check One)
| | |
|(Full Payment (To Logic) |Amount: $_____________________________________ |
|(Down Payment (Only to Logic) |Amount: $_____________________________________ |
|(Split Payment (DP & Pmt to HMH) (Indicate Split) |DP to Logic $__________To HMH $_______________ |
| | |
|(HMH Payment (Check One) |Amount: $____________________________________ |
|( One Time | |
|(Monthly Reoccurring Due Date:___________ | |
| | |
This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and BANK a reasonable opportunity to act on it.
Authorized Signature: ________________________________________________ Date: __________________
(Account Holders)
________________________________________________ Date: _________________
NOTE: ALL WRITTEN DEBIT AUTHORIZATIONS ARE NON-REVOKABLE WITH THE EXCEPTION OF FUTURE HMH REOCCURRING.
ALL PAYMENTS ARE A ONE TIME DRAFT AUTHORIZATION EXCEPT THE HMH REOCCURRING.
-----------------------
PLACE VOIDED CHECK HERE.
FAX FORM to 888-633-0607.
ATTENTION ACCOUNTING DEPT
OR
SCAN & EMAIL
TO
accounting@
................
................
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