Set Up or Update Automatic Payment of Premium from your checking or savings account

First Name:                              Last Name:                     

Your Email Address:
 We will only contact you via email if we have any questions.

Please send me my invoices by email in the future.  A check indicates Yes

Phone Number:

Name of group or individual on billing invoice:

Please provide your client ID:

Ex: 123456-0 or 91010-150 as shown on your invoice

I (We) acknowledge that the origination of ACH transaction to my (our) account must comply with the provision of U.S. Law and the Rules of the National Automated Clearing House Association. I (We) further acknowledge that I (we) have retained a copy of this authorization when I (we) signed it.
You hereby authorize and request  Wolfpack Insurance Services, debit funds from your account at the financial institution indicated, and credit the funds according to the above instructions. Funds need to be on deposit at the designated financial institution on the evening prior to the effective date of the ACH debit. In the event of an error, you authorize  Wolfpack Insurance Servcies, Inc. to take any and all action required to correct the error.
You must notify Wolfpack Insurance Services, Inc. in writing if you would like to make any changes or to cancel the authorization.
You agree to indemnify and hold  Wolfpack Insurance Services, Inc. harmless from all costs, including attorney’s fees, (to the extent permitted by law), damage or claims related to Wolfpack Insurance Services, Inc. action in refusing payment of the item, including claims of any joint account-holder, payee, or endorsee, or in failing to cancel or process an item as a result of incorrect information provided by you.   Upon cancellation Wolfpack Insurance Services, Inc. will collect any outstanding premium due.
By clicking the Submit Form button below, you certify that the information you have given on this ACH Debit Authorization Agreement for Direct Payments is complete, true, and submitted for the purpose selected above.

Automatic draft failures are subject to a $15.00 fee.

Bank Name:

Choose Checking or Savings:         Choose the Type of Account:

ABA Routing Numbers (First nine digit number on left hand bottom of your check):

Account Number (Second series of numbers on the bottom of the check):

Funds are drafted on the 15th of the month prior to the month of coverage for DeltaCare and Individual or COBRA accounts.

Funds are drafted on the 25th of the month prior to the month of coverage for Trust Group accounts.

If you are making this selection after the draft date, you must pay your current invoice to avoid any lapse in coverage.  

If you would like to pay the current invoice please click on the following link: 
One Time Premium Payment from your Bank Account.

By submitting this form you are electing to set up an automatic payment and accept the conditions listed on this form.

Your bank statement will reflect an automatic draft to "Wolfpack Ins"