EmailMe Form - eCheck Submission

Your Email Address:

Account Holder's Name:

Joint Account Holder, if applicable:

Bank Name:

Check Number: *

Your Street Address:

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Date:

MM / DD / YYYY

PAY TO THE ORDER OF: *

AMOUNT: *

Memo:

Routing # *

Confirm Routing # *

Checking Account # *

Confirm Checking Account # *

Is this payment for a new policy?

No

Yes

If no, provide the Policy or Invoice Number relating to this payment:

Your Initials:

Your Routing Number and Account Number can be found at the bottom of your check. DO NOT INCLUDE THE CHECK NUMBER - it may be before or after your account number.

Terms
By clicking "Submit" you agree to the following: By using this electronic check form I am authorizing the recipient identified by the "Pay to the order of" field to withdraw funds from the financial institution account that I have provided. I confirm that I am authorized to submit payment from this account. I will not hold the recipient of these funds liable for my financial institutions failure to pay funds. I am authorizing the US currency represented in the "Amount" field to be withdrawn for this transaction only.