EFT Enrollment


		VERMONT MUTUAL INSURANCE GROUP_® Electronic Funds Transfer (EFT)
Electronic Funds Transfer (EFT)
Payment Plan Options:
Enrollment Change Bank Information Change Withdrawal Date
Payment Plan Option: Enrollment


Please complete the Personal information below
	Name	Required
	Address 1	Required
	Address 2
	City	Required State Required Zip Required
	City	Required State Required Zip Required
	Phone
	Email


Please list the Policy/Account Number(s) that you would like to pay through EFT.

	Policy/Account Number	Withdrawal Date Withdrawal Date	Payment Plan Payment Plan
* The policy number(s) listed above may be changed by the company at issuance or renewal.
Please check other lines of coverage to be included for EFT: HO PA DF PU IM BP CA CU


Banking Information
	Account Holder Name
	Name of Financial Institution
	Bank Transit/Routing Number
	Type of Account
	Type of Account	[ ] Checking - Please include a voided check [ ] Savings - Please include a deposit ticket
	Checking/Savings Account Number
	Retype Checking/Saving Account Number

	I agree to the Terms & Conditions

Signature of Account Holder ____________________________________________ Date __________________
Terms & Conditions: I hereby request and authorize Vermont Mutual Insurance Group® to debit/credit my bank account as payments for my account/policy number(s) become due. I understand that the amount deducted from my account could vary due to changes in my insurance coverage and that Vermont Mutual Insurance Group® may send me a written notice if my deduction amount changes. I agree that if a debit/credit is dishonored, the bank shall have no liability even if the dishonored debit/credit results in the forfeiture of insurance. This authority is to remain in full force until Vermont Mutual Insurance Group® and the above named bank have received written notice from me of its termination. To stop the next scheduled deduction, written notification must be received ten business days prior to the next deduction. No payment to Vermont Mutual shall be deemed to have been made unless and until Vermont Mutual receives actual credit.
Disclaimer: Vermont Mutual Insurance Group® has the right to deny eligibility to this enrollment request for any reason or to discontinue the use of this enrollment if your account/policy number(s) are not in good standing or if there are insufficient funds on the scheduled deduction date. A letter of rejection regarding this agreement will be sent to you if you are not eligible or if you become ineligible.