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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 I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as coverage is requested.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
My Billing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
My Billing Phone
*
My Billing Email
*
Account Details
Type of Account
*
Please select
Bank Account
Credit Card
*
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
This field is hidden when viewing the form
*
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
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
Expiration Date
Security Code
Cardholder Name
Bank Account
Name on Account
Bank Name
Routing Number
Account Number
Checking
Savings
Account Type
Name on Paypal Account
*
Paypal Account Email
*
TOA Sponsor / Applicant Details
Entity or individual insurance is being payed for
Type of coverage holder
*
Please select
Individual
Entity
Coverage holder name
*
First
Middle
Last
Coverage holder name
*
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
*
Click here to sign
Reset
Initials
Generated signature initials from name
*
Please create your initials
*
Click here to sign
Reset
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