ACH Form 2025 / 2026

ACH Form 2025 / 2026

Use this form to update your banking info for direct deposits from Classic Insurance Agency LLC DBA MedicarePrepare. Note: This does not update individual Carriers. You will need to contact them individually.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Routing #
Account #
Type of Account
IMPORTANT! PLEASE READ AND SIGN BEFORE SUBMITTING

I hereby authorize Classic Insurance Agency LLC DBA MedicarePrepare to deposit any amounts owed to me by initializing credit entries to my account at the financial institution/s ("Bank"),indicated above. Further, I authorize the Bank to accept and credit any entries indicated by Classic Insurance Agency LLC DBA MedicarePrepare to my account.

In the event that Classic Insurance Agency LLC DBA MedicarePrepare deposits funds erroneously to my account, I authorize Classic Insurance Agency LLC DBA MedicarePrepare and the Bank to debit my account for an amount not to exceed the original amount of the erroneous credit without notification to me.

This authorization is to remian in full force and effect until Classic Insurance Agency LLC DBA MedicarePrepare has received written notice from me to terminate this agreement, or change the corresponding Banking information in a reasonable time frame to afford action.

Changes to Banking information is to be done by completing a new ACH Payment Form.

Questions: (918) 420-9999

Bob@MedicarePrepare.net
Date

MonthDayYear
Date
Signature
Should be Empty: