ACH Form

Recurring Payment Authorization form
ACH / Credit Card Payment Authorization Form Schedule your payment to be automatically deducted from your checking, savings, or credit card account. Just complete and sign this form to get started! ACH Payments will make your life easier:

• It's convenient (saving you time and postage).
• Your payment is always on time (even if you're out of town), eliminating late charges.
• All your changes will be processed on the same date they are received.

Here's How ACH Payments Work: You authorize charges to your checking or savings account based on quoted and issued coverage. The charges will appear on your bank statement as an “ACH Debit.”
I authorize Agents House Inc to charge the bank account indicated below for any charges related to coverage/benefits issued by TRUCK OWNERS ASSOCIATION (TOA) for named Payor,unless alternative payment information is provided upon enrollment. These charges may include, but are not limited to, down payments, recurring monthly payments, endorsement payments, taxes and fees incurred in relation to any coverage/benefits written through TOA. This form also applies to any risk or coverage submitted by named payor to cover a third party.I understand that this authorization will remain in effect until I cancelled it in writing, and I agree to notify Agents House Inc in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as coverage is requested. In the case of an ACH transaction being rejected for Non Sufficient Funds (NSF) or any action by Payor or Payor bank. I understand that the charge may be processed again within 30 days, and agree to an additional $35.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form. ALL CHARGES APPLICABLE ONLY TO REQUESTED COVERAGES/BENEFITS BY SPONSOR/MEMBER DESCRIBED BELOW
TOA Payor / Applicant Details
Entity or individual insurance is being payed for
Type of named Insured / Applicant*
Coverage holder’s name on policy*
First Middle Last
Coverage holder’s name on policy*
My Billing Address*
Street Address Address Line 2 City State ZIP Code
My Billing Phone*
My Billing Email*
Account Details
Type of Account*
*
- I understand and agree, that Using Credit card payment option, to payment amount will be added a 3.5% credit card fee
*
- I understand and agree, that Using Paypal payment option, to payment amount will be added a 3% Paypal fee
*
- I understand and agree, that Using Bank payment option, to payment amount will be added a 1% bank fee
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Bank Account
Name on Account Bank Name Routing Number Account Number Account Type
Name on Paypal Account*
Paypal Account Email*
Signed by Name*
First Last
Title of person signing*
Signing method*
- use your name as signature
- sign online with e-Signature
Signature
Generated signature from name*
Please sign*

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Sign above
Initials
Generated signature initials from name*
Please create your initials*

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ACH Form

Recurring Payment Authorization form

TOA Payor / Applicant Details

Account Details

Signature

Initials

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