Eft Form

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Electronic Funds Transfer Authorization Form

Please complete this form and return email to:


[email protected]

Overview
“Payee Name” given below hereby:
(1) authorizes Fortune General Insurance Corporation to make payments by electronic transfer,
(2) certifies that it has selected the depository institution indicated below to receive such transfers, and
(3) directs that all such Electronic Funds Transfers be made as provided below.
(4) Agrees to issue the corresponding receipts to support the aggregate payment received facilitated via direct fund transfer.
It is understood as well that the submittal of the said document is a pre-requisite for the succeeding direct online payments.

Please complete the following information about your company:

Company/Payee Name:       Address:      


Vendor ID #(if known):
      Line 2, or PO Box:      
Contact Name:       City:      
Telephone #:       Zip Code:      
Email Address (Required):
      Postal Code/Country:      
(International Only)

Please complete the following information regarding your depository bank:


We would like our disbursements paid via electronic deposit into the following bank account:
Depository Bank Information :

Account Type: Checking Savings Currency:      


Bank Name:       Bank Address:      
Bank Routing #:       Line 2, or PO Box:      
Bank Account #:       Bank City:      
Payee Name on Account:       Bank Zip Code:      
Postal Code/Country:      
(International Only)
Depository Bank Information (International Bank Accounts):

SWIFT/SORT Code:       IBAN #:      


(if applicable)

Please sign and date below:

            /     /     


Authorizing Signature Printed Name Date

Version 24 Jul 2020 Page 1 of 1


Fortune General Confidential and Proprietary Information

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