By submitting this form, you give us (FAF) permission to debit your agency 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.
You understand that because this is an electronic transaction these funds may be withdrawn from your account as soon as the above noted transaction date.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. Financed premiums must be authorized and paid directly from a finance company.
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.