Set Up Automatic Deposit of Commissions

Please provide your AgentID:                  Person making this request:
          

Email:


Phone Number:


Email address to send Commission Statement to:


Name of Agent or Agency:


Bank Name:


Choose Checking or Savings:         Choose the Type of Account:
CheckingSavings                             PersonalCorporate

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):




By clicking submit, you authorize Wolfpack Insurance Servicices, Inc and the financial instituation to electronically deposit any payment
into the designed account and to correct my account for any amounts deposited to which I am not entitled.

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, Inc. to credit funds to your account at the financial institution indicated, and credit the funds according to the above instructions. 
 
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 Servcies, Inc. harmless from all costs, including attorney’s fees, (to the extent permitted by law), damage or claims related to Wolfpack Insurance Services action in refusing 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.   

By clicking Submit Form below, you certify that the information you have given on this ACH Credit Authorization Agreement for Direct Payments is complete, true, and submitted for the purpose selected above.