Insurance Claim Payout Direct Deposit Authorization Form

Policyholder Information

Full Name

Policy Number

Mailing Address

Phone Number

Email Address

Bank Account Information

Bank Name

Branch/Location

Account Holder Name

Account Number

Routing Number (or SWIFT/IFSC for international)

Account Type

Authorization & Agreement

I hereby authorize the insurance company to deposit my claim payout directly into the account indicated above. I certify that the information provided is true and correct, and I agree to notify the company of any changes to the information provided. I acknowledge that this authorization will remain in effect until I submit a written cancellation.

Signature

Date