ACH Recurring Monthly Payment |Stonemark |Insurance Payment

To set up ACH Recurring Monthly Payments, complete the form below. Please allow up to 2 business days for processing your request. Past due accounts will be debited as soon as the form is processed.

I (we) hereby authorize IPFS Corporation, hereinafter called Lender, to initiate debit entries to the chequing/savings account, depository name (hereinafter called DEPOSITORY) below and to debit the said account.

Form Completed By:
Agent / BrokerBorrower / Insured

Account Type
ChequingSavings

For Credit Card payments, please call 800.955.0083

Bank Name

Bank 5 Digit Transit Number

Bank 3 Digit Institution Number

Bank Account Number
(Please double check your entry to avoid possible return fees.)

Name on Bank Account

Account Number Location Information

I agree this authorization is to remain in full force and effect until Lender has received written notification from me of its termination in such time and in such manner as to afford Lender and DEPOSITORY a reasonable time to act on it. I understand that the amount being transferred from the account could vary based on changes made to the insurance coverage, and that I will be notified of the changes prior to the transfer effective date.

Borrower / Insured Name

Contact Phone #

Contact Email Address

Select one of the following:
Account # (begins with 1071)Quote Number

Account #

Quote Number

I am an authorized signer or authorized representative for this account, and I have signed this sheet to certify this transaction.

Electronic signature of account holders or authorized signers

First

Last