I (we) hereby authorize Amelia Underwriters, Inc. hereinafter called “company”, to initiate payment credit entries to my (our) checking account indicated below and the depository named below, hereinafter called The Bank, to credit the same to such account.
This authorization is to remain in full force and effect until the “company” has received written notification from me (us) of its termination in such time and in such manner as to afford AU and The Bank a reasonable opportunity to act on it.
Note: By signing below, you are choosing to have returns electronically transferred into the account provided. A detailed log report for any monthly returns can be accessed anytime by logging into our website. This monthly report can also be emailed upon request. Please provide the name and e-mail address for the authorized agency representative to receive these statements when requested.
By typing your name below, you agree to our terms and conditions.​
