FULMONT MUTUAL INSURANCE COMPANY   

Authorization Agreement For
Automatic Deposit (ACH Credits) and/or E-checks

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Form #ACHDEP01 06/98 | See Directions Below

I (we) hereby authorize Fulmont Mutual Insurance Company, hereinafter called COMPANY, to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my (our) checking account indicated below and the depository named below, hereinafter called DEPOSITORY, to credit and/or debit the same to such account.

 
DEPOSITORY NAME:    		________________________________
 
BRANCH:		 ________________________________
 
CITY:		 ________________________________
 
STATE: ___________		 ZIP CODE: ____________
 
TRANSIT ABA NO:		 ________________________________
 
ACCOUNT NO.:		 ________________________________

This authority 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 DEPOSITORY a reasonable opportunity to act on it.

  
NAME: (please print)            		________________________________
  
POLICY NUMBER:		 ________________________________
  
SIGNATURE:		 ________________________________
  
SIGNATURE:		 ________________________________

Method of Payment:

____ Please pay my premium in full.
____ Please Specify here either four, six, or eight payments, each to be withdrawn from my account every 60 days from policy issuance. (Total billing period is 180 days)

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Directions For Paying Your Premiums Through ACH Transactions

1. If you wish to have Fulmont Mutual Insurance Company make an automatic withdrawal from your checking or savings account to pay your insurance premium, please print this page and complete this form.

2. Please complete your bank information - name, branch, city, state, zip.

3. Please fill in the TRANSIT ABA NUMBER from your deposit slip for your account. It is a nine-digit number, usually found on the left-hand side of your deposit slip. Then, please fill in your account number, which usually can be found to the right of the Transit ABA Number on your deposit.

4.Please complete the name, policy number and date. All account parties must sign where indicated.

5. Please designate how you wish to pay your premium. Please note - if you designate Fulmont Mutual to withdraw your premiums from your account, all future billings will be deducted unless we are notified in writing at least 30 days in advance of your due date.

6. You will continue to receive annual premium notices, change endorsements and renewal policies directly from the Company or your Agent.

7. Please mail, fax or e-mail the completed form to us.

revised 06/2012-mas

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