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EPIC Agency EFT Authorization Form Please complete requested information, attach a voided check, and sign at the bottom. EFT is offered for EPIC Personal Auto policies. |
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Please type or print: Insured(s) Name: _______________________________________________ Insured’s Daytime Phone Number: _________________________________ Insured’s email address: _________________________________________ Policy Number: _______________________________________________ Financial Institution Name: ______________________________________ Financial Institution Routing Number: _____________________________ Account Number: _____________________________________________
Account Type: __Checking __ Savings By completing this form, providing a voided check, and signing below, I am authorizing EPIC Agency, Inc. and the financial institution named above to initiate monthly deductions from my bank account identified on the enclosed check to pay for my insurance policy and any renewals thereof, and to deposit any credits/refunds into that account. This authority will remain in effect until I notify you in writing to cancel it.
Signature: _________________________________ |
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PLEASE ATTACH A VOIDED CHECK HERE Click here for a check example for filling out the form. |
Please mail or fax form to: |