ACH Authorization

ACH Authorization Form
Business Name*
For agency commission, enter your Agent Number. For insured payments, enter your Insured's Account Number*
Email*
example@example.com
Account Holder / Business Name as Registered on Bank Account*
Routing Number*
must be 9 numbers - no spaces
Bank Account Number*
must be 9-12 numbers - no spaces
Bank Name*
Bank Branch*
City, State
Type of Bank Account*

CheckingSavings
I hereby authorize Wilmington Insurance Company, Inc., hereinafter called Company, to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any debit entries in error to my account indicated above and the depository named above, hereinafter called Financial Institution, to credit and/or debit the same to such account.

This authority is to remain in full force and effect until Company has received written notification from me of its termination in such manner as to afford Company and Financial Institution a reasonable opportunity to act on it.

Note: Setting up automatic payments may take up to 10 business days to be effective. If you have any inquiries about billing, please call us at 1-855-639-9688 or email us at billing.al@wilmingtoninsco.com
Signature*

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Date*

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ACH Authorization Form