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One (1) Time ACH Payment Authorization Request

Complete and succesfully submit this form to authorize Firestone Agency of Florida, Inc. (FAF) to debit a one (1) time debit to your agency checking or savings account.

By submitting this form, you give us (FAF) permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account.

Agency Billing Information

Agency Bank Details

I understand the because this is a single one-time electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date.

I declare that I have read and understand all of the above information and that the facts stated in it are true and accurate.

You understand that because this is an electronic transaction these funds may be withdrawn from your account as soon as the above noted transaction date. FAF is not responsible for premium payment. It is the obligation of the retail producer to secure premium payment.

If this transaction has been requested in error or any discrepancies contact us immediately.

Please check the top of this form for confirmation. Incomplete inaccurate information will result in no transaction request.