AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)

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*Policy Holder Name
*Policy Number
*Choose One: New Authorization Agreement
Change to Original Authorization Agreement
 
I (we) hereby authorize Security Mutual Insurance Company, hereinafter called COMPANY, to initiate debit entries to my (our)

*(select one) Checking Account Savings account

indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to credit the same to such account and to initiate, if necessary, debit entries/adjustments for any credit entries in error the same to such account. I (we) acknowledge the origination of ACH Transactions to my (our) account must comply with the provisions of U.S. Law.
*Depository Name:
*City
*State
*Zip
*Routing Number
*Account Number
 
   
This authority is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.
   
*Email
*Phone
   
*Please type your First and Last Name
  
*Date (mm/dd/yy) / /
   
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms.