Authorization for Electronic Funds Transfer

Electronic funds transfer lets you authorize your bank or financial institution to automatically deduct your installment premiums from either your checking or savings account.

When you pay by EFT, you save on monthly installment charges. You also save check-writing costs an postage, because you do not mail your payments. This option also eliminates risk of late payment and the potential cancellation of your policy.

For information on charges relating to EFT check with your agent. You can switch back to payment by mail at any time by notifying us.

To authorize your payment to be automatically deducted, simply fill out the required information below.

I authorize Preferred Mutual Insurance to make arrangements with the bank or financial institution specified to deduct my insurance premium from the account identified below. I understand that I may discontinue participation in the EFT program at any time by notifying the company.

Policyholder's Name:
Policy Number:
Policy Number:
Policy Number:
Bank or Financial Institution:	Enter Name & Address.
Checking Account Number:
Savings Account Number:
Bank Routing Number:
E-mail Address:
Daytime Phone Number:

NOTE: Your account will be set up on EFT upon receipt. Your first withdrawal will NOT begin if there is a payment due. Once payment has been processed your next installment will be withdrawn EFT.