Electronic Check Processing - Check Information Collection

Please fill in the details below. All fields are mandatory.

Application/Policy Number:

Insured Information

Named Insured:

Contact Information

Street:

City:

State:

Zip:

Email:

Confirm Email:

Telephone Number:

Bank Details

Account Type: Checking Savings

Account Holder's Name:

Bank Name:

Bank Routing Number:

Bank Account Number:

Confirm Account Number:

Payment Amount

Amount $:

I authorize Statewide Insurance Corp. to debit the bank account indicated in this web form, for the noted amount on today's date. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that the business may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25.00 charge for each attempt (returned NSF) which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I will not dispute merchant debiting my checking/savings account, so long as the amount corresponds to the terms indicated in this web form.

All information you have provided represents you and your checking or savings account. No information you have provided is property of any other individual or individuals.