Flood Insurance Premium ACH Authorization

Policyholder Name:

Policy Number:

Property Address:

Bank Account Information

Bank Name:

Bank Routing Number:

Bank Account Number:

Account Type:

Authorization

Amount (USD):

Frequency:

Effective Date:

Comments / Notes:

By signing below, I authorize the above-named insurance agency/company to initiate Automated Clearing House (ACH) debit entries from my account at the financial institution indicated above for the flood insurance premium payment(s).

Authorized Signature:

Date: