Pathfinder Check Draft Authorization Form

Pathfinder Check Draft Authorization Form
Name*

First NameLast Name
Policy Number*
Check Number*
Payment Amount*
Upload an image or scan of your check here.*

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I authorize Pathfinder LL&D Insurance Group, LLC to use the attached copy of my check as a check draft. This draft will be debited automatically from my account. I understand that I presently have these funds available in my account to process this draft. This is to be done on a one-time only basis.
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Date*

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Date
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