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Request a single policy authorized transaction only. Does not provide
authorization for any additional unrelated debits or credits to your account.

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I understand the because this is a single one-time electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date.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You understand that because this is an electronic transaction these funds may be withdrawn from your account as soon as the above noted transaction date. Firestone Agency of FL, Inc. 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.

In the event of payment rejected for Non-Sufficient Funds (NSF) you understand Firestone Agency of FL, Inc. may at its discretion attempt to resubmit the charge again within 30 days, and you agree to an additional $25.00 NSF charge for each attempt returned NSF, which will be initiated as a separate transaction from the authorized payment. You acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. You will not dispute the Firestone Agency of FL, Inc. ACH debit with your financial institution as long as it corresponds to the amount due and date.

ACH Assistance

Firestone Agency of Florida, Inc.
Wholesale Insurance Brokers | MGA

Boca Raton, Florida
International Plaza
7280 West Palmetto Park Road
Suite 106-N
Boca Raton, FL 33433
Call Us (954) 341-8331

Ponte Vedra, Florida
Valley Ridge Professional Park
4210 Valley Ridge Blvd
Suite 127
Ponte Vedra, FL 32081
Call Us (800) 683-1150

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