Insurance Agent | League City, TX

EFT Authorization

First Name

Email Address

Phone Number

Billing Address

Bank Routing Number (The far left 9 digits at the bottom of your check (must be from the check or bank letter, not a deposit slip.))

Bank Account Number (PLEASE, if you have a Credit Union make sure this is from the bottom of your check or bank letter. Your member number is NOT the account number, if you enter your member number the payment will be rejected.)

Policy/App Number (Enter your quote, application, policy number or the description of the policy you're wanting to pay.)

Notes (Optional)

Confirmation and Agreement

Check the box above if you to agree and consent ot the following:

We will draft the amount discussed to effect your coverage. If you are unsure of the amount being drafted please contact the agency directly at 832-779-8430 before filling out this form.

By signing/submitting this form, I have read and agree to the terms and conditions relayed in this form in its entirety.

I authorize Liz Miller Agency, Inc. &/or its affiliates to make payments to the account(s) indicated in this authorization form according to the terms outlined herein and in consideration of terms and conditions set forth by Liz Miller Agency, Inc. &/or its affiliates. This payment authorization is valid until revoked in writing by me or I am notified in writing by Liz Miller Agency, Inc. &/or its affiliates. I certify that I am an authorized user of this account and that I will not dispute the payment with my banking institution, so long as the transaction corresponds to the terms indicated in this form and in consideration of terms and conditions set forth by Liz Miller Agency, Inc. &/or its affiliates and in accordance with my banking institution.

By signing/submitting this form you give us permission to debit your account for the amount indicated on or within 30 business days after the date signed. This/These form(s) is/are not the contract(s) of insurance and is not an offer or guarantee of coverage. The provisions of the policy(ies) shall prevail in all respects.