Unearned Commission ACH |USA | Canada|Stonemark

To make an Unearned Commission ACH Payment, complete the form below. Please allow up to 2 business days for processing your request.

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.

Account Type
ChequingSavings

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

Agency/Brokerage Name

Agent/Broker Phone #

Email Address

Borrower / Insured Name

Policy #

Select one of the following:
My Account # begins with 1080My Account # begins with 1071

Account #

UEC Amount
$

I (we) hereby authorize IPFS Corporation, to use this information on this account as a payment and to use this information to make a one-time electronic funds transfer from my account or to process the payment as an electronic transaction. I am an authorized signer or authorized representative of the account, and have signed this sheet to certify this transaction.

Electronic Signature

First

Last