ACH AUTHORIZATION FORM

Carrier & Policy Information

Insurance Carrier

Policy Number (Leave Blank If Unknown)

Bank Account Holder

Please complete this form to authorize Peak Insurance to make a payment using your Bank Account (ACH Payment) directly to the Insurance Carrier.

Name(s) on Bank Account (Business Name If Used) *

Routing Number *

must be 9 numbers - no spaces

Account Number *

must be 9-12 numbers - no spaces

Bank Name *

Bank Branch *

City, State

Type Of Bank Account *

Example: Personal Checking, Business Checking

Personal Checking
Personal Savings
Business Checking
Business Savings
Other
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Bank Phone Number

Authorization To Withdraw Payment

I authorize Peak Insurance to initiate an ACH payment from my bank account as specified above, on my behalf, to the designated insurance carrier for the purpose of paying my insurance premium.

I understand this authorization is valid for one-time use only. I acknowledge that I am responsible for ensuring sufficient funds are available in my account for this transaction.

Authorization

Amount To Be Withdrawn

$

Date Funds To Be Withdrawn On *

BY CHECKING THIS BOX, I HAVE READ AND AGREED TO THE ABOVE TERMS AND AUTHORIZE PEAK INSURANCE TO MAKE THIS PAYMENT ON YOUR BEHALF.

Bank Account Holder Signature

Clear

Sign Here

Date Signed By Bank Account Holder

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