ACH Claim ReimbursementAuthorization Form - QBE Insurance



1206552705ACH Claim ReimbursementAuthorization Form00ACH Claim ReimbursementAuthorization FormBy submitting this document, your agency/policyholder will be able to receive claim reimbursements quickly and easily. The reimbursement will be electronically deposited to the bank account assigned. To sign up, we need authorization from the agency principal and the necessary bank information. For questions and to submit this authorization form, please contact our premium department at US-QBE-AH-SL-Premium@US..Please check one: FORMCHECKBOX ?New FORMCHECKBOX ?Change FORMCHECKBOX ?CancelPayee Information:Producer NamePhone Number FORMTEXT ????? FORMTEXT ?????Street AddressCityStateZip FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Contact Name FORMTEXT ?????Contact NumberContact Email FORMTEXT ????? FORMTEXT ?????Financial Institution Information:Entity to be credited FORMCHECKBOX ?Administrator account FORMCHECKBOX ?Policyholder accountAccount Type FORMCHECKBOX ?Checking FORMCHECKBOX ?SavingsName of Financial InstitutionBank Routing Number FORMTEXT ????? FORMTEXT ?????Address of Financial InstitutionAccount Number FORMTEXT ????? FORMTEXT ?????Authorization:I hereby authorize QBE Insurance Corporation to initiate entries to the above checking/savings at the financial institution listed above, and, if necessary, initiate adjustments for any transactions credited/debited in error. I understand that this authorization will remain in effect until cancelled in writing or the underlying contract is terminated. I agree to notify QBE Insurance Corporation in writing of any changes in my account information or termination of this authorization at least 10 days prior to the next billing date.Principal Name and Title (print) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SignatureDate ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download