ACH

One (1) Time ACH Payment Authorization Request

Complete and successfully submit this form to authorize Firestone Agency of Florida, Inc. (FAF) to debit a one (1) time transaction from your agency checking or savings account.

By submitting this form, you give us (FAF) permission to debit your agency account for the amount indicated on or after the indicated date. This is permission for a single transaction only and does not provide authorization for any additional unrelated account debits or credits.

Date

I authorize Firestone Agency of Florida, Inc. (FAF)

to charge my agency bank account indicated below for the following amount:

Withdrawal Authorization Date:

This payment is for the following policy number:

Policy Named Insured:

Agency Billing Information

Agency Location Address

City, State, ZIP Code

Agency Phone Number

Agency Contact Email

Agency Bank Details

Account Type

Checking

Savings

Bank Name

Routing Number

Bank Account Number

I understand the because this is a single one-time electronic transaction, these funds may be withdrawn from my account indicated above as soon as of the noted transaction date.

I declare that I have read and understand all of the above information and that the facts stated in it are true and accurate.

Date

You understand that because this is an electronic transaction these funds may be withdrawn from your account as soon as the above noted transaction date. Firestone Agency of FL, Inc. is not responsible for premium payment. It is the obligation of the retail producer to secure premium payment. Financed premiums must be authorized and paid directly from a finance company.If this transaction has been requested in error or any discrepancies contact us immediately.

Please check the top of this form for confirmation. Incomplete inaccurate information will result in no transaction.In the event of payment rejected for Non-Sufficient Funds (NSF) you understand Firestone Agency of FL, Inc. may at its discretion attempt to resubmit the charge again within 30 days, and you agree to an additional $25.00 NSF charge for each attempt returned NSF, which will be initiated as a separate transaction from the authorized payment. You acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. You will not dispute the Firestone Agency of FL, Inc. ACH debit with your financial institution as long as it corresponds to the amount due and date.

ePay ACH

One (1) Time ACH Payment Authorization Request

ACH Assistance