Ocean Harbor Insurance Company Personal Automobile …

[Pages:1]Policy Number: Named Insured:

Ocean Harbor Insurance Company Personal Automobile Program

Electronic Funds Transfer (EFT) Authorization Form

Producer Name: Producer Code:

As the Named Insured and with my signature below I authorize All Star General Insurance Agency, Inc. ("All Star") to electronically deduct installments for payment of my insurance policy premiums, subsequent renewal down payment and installments, and to initiate credit entries in the event of erroneous charges. I hereby authorize the Financial Institution indicated below to accept and post these transactions to my account.

Furthermore, I authorize All Star to adjust said transactions to reflect any premium changes and policy renewals. All Star agrees to notify me, at least 10 days in advance, in the event that the electronic transaction will be greater than or less than the scheduled debit amount.

CANCELLATION: I am aware that in order to terminate this authorization the policy written on the EFT payment plan must be cancelled and I must obtain a new policy through my broker. This authorization will remain in effect until I provide written notice of cancellation to All Star in such manner as to afford All Star and the Financial Institution reasonable time to act on it. I am also aware that in the event funds from my financial institution are not accessible to All Star for my payment my policy will cancel for non-payment of premium.

I understand that this authorization allows All Star to deduct from my checking account amounts due to All Star including earned premium and fees should my insurance coverage be cancelled for any reason.

In the event that my Financial Institution or account number changes, I acknowledge that ten (10) days advanced notice must be given to All Star before the changes take affect. I understand that I will be receiving a payment schedule with the due dates and amounts of future withdrawals. Upon receipt, I will retain the payment schedule for future reference.

Bank Information Name(s) on Account:

Account Number:

Name of Bank:

Routing/ABA Number:

DO NOT SIGN THIS DOCUMENT UNTIL YOU READ AND UNDERSTAND IT.

_____________________________ _________

Account Holder Signature

Date

___________________________________ __________

Second Account Holder Signature (if applicable)

Date

To ensure accuracy, please attach a sample check and mark it as VOID.

Customers of credit unions should verify their account numbers as some credit unions may use different account number than the numbers printed on checks.

CA-AS OH EFT AUTH 07/08

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