ACH Direct Deposit Authorization Form

SSIUSOUTHSHOREINSURANCE
ACH DIRECT DEPOSIT AUTHORIZATION FORM

The purpose of this form is to authorize automatic direct deposit transactions.
I hereby authorize SSIU, LLC to initiate automatic deposits to the account at the financial institution named below. I also authorize SSIU LLC to reverse deposit transactions from this account in the event that a credit entry is made in error.

Further, I agree not to hold SSIU, LLC responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or my financial institution or due to an error on the part of my financial institution in depositing funds to my account.

This agreement will remain in effect until SSIU, LLC receives a written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form to SSIU.
COMMISSION DEPOSIT ACCOUNT INFORMATION
Name of Person or Organization as it appears on the account*
Name of Financial Institution*
Routing Number*
Account Number*
Account Type*

CheckingSavings
PersonalBusiness
Address*

Agency Address on Account

Street Address Line 2

City State Zip CodeState / Province

Postal / Zip Code
RETURN OF PREMIUM DEPOSIT ACCOUNT INFORMATION
Same As Above
Name of Person or Organization as it appears on the account
Name of Financial Institution
Routing Number
Account Number
Account Type

CheckingSavings
PersonalBusiness
Address

Agency Address on Account

Street Address Line 2

City State Zip CodeState / Province

Postal / Zip Code
Remittance Advice/ACH Notification Email Address:*
Accounting Contact Name:*
Authorized Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

SSIUSOUTHSHOREINSURANCE

ACH DIRECT DEPOSIT AUTHORIZATION FORM

COMMISSION DEPOSIT ACCOUNT INFORMATION

RETURN OF PREMIUM DEPOSIT ACCOUNT INFORMATION