Sign Up for Auto Draft ONLINE below or download our SIGN-UP FORM and email to: info@firstsolutionfinancial.net <<<< >>>> Sign Up for Auto Draft PaymentsAcct./App ID/Policy Number(s):*Insured NameAcct./Policy/App ID#Effective Date Please select payment method:*Credit/Debit CardCheck/Bank Draft AUTO DRAFT Authorization CREDIT/DEBIT CARDAgreement Auto Draft Authorization First Solution Financial Services (FSFS), offers an Auto Draft program to automatically charge or debit your insurance policy payments from your credit card in accordance with your Insurance Premium Finance and Security Agreement (“Finance Agreement”) with FSFS. To sign up, simply complete the below Credit Card Payment information and submit your completed form online to FSFS. Please note, you may still receive bills for payments that cannot be automatically debited. Please allow (5) business days for processing of this authorization. This agreement does not modify, replace, or negate any provisions of your Finance Agreement. Your prepayment or failure to process a timely payment according to the payment schedule in the Finance Agreement may still result in a Prepayment service fees, loss of Security Interest, delinquency charges, cancellation charges, or other additional charges. Please review the Auto Draft Authorization below and your Finance Agreement for additional terms and conditions. Credit Card Payment*** All credit cards are subject to a 3.25% processing fee added automatically to the amount charged ***Name on credit card:*Card Type*VisaMastercardAmerican ExpressDiscoverBilling Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Credit Card Number:*CVN Number:*Expiration Date:*I hereby authorize First Solution Financial Services to charge my credit card in the amount of ___(enter amount)___*On the ___(enter day)___day of each month*Starting On ___(enter date)___* MM DD YYYY Ending On ___(enter date)___ in payment of my insurance policy.* MM DD YYYY Auto Draft Agreement* I agree to this auto draft By clicking here you agree to this auto draftSignatureSignature Date: MM DD YYYY AUTO DRAFT Authorization CHECK/BANK DRAFTAgreement Auto Draft Authorization First Solution Financial Services, offers an Auto Draft program to automatically charge or debit your insurance policy payments from your bank account in accordance with your Insurance Premium Finance and Security Agreement (“Finance Agreement”) with First Solution Financial Services . Please note, you may still receive bills for payments that cannot be automatically debited. Please allow (5) business days for processing of this authorization. To sign up, simply complete the below Auto Draft portion of this form, read and sign the Auto Draft Authorization portion below, and submit your completed form online to First Solution Financial Services . This agreement does not modify, replace, or negate any provisions of your Finance Agreement. Your prepayment or failure to process a timely payment according to the payment schedule in the Finance Agreement may still result in a Prepayment service fees, loss of Security Interest, delinquency charges, cancellation charges, or other additional charges. Please review the Auto Draft Authorization below and your Finance Agreement for additional terms and conditions. I hereby authorize First Solution Financial Services to initiate pre-authorized debit transfers on behalf of my business using the information outlined below: Name of Account Holder:*Bank Account #*Bank Routing #*Bank Name:*Bank City:*Bank State:*Draft Payment Options ***PLEASE NOTE - each Check/Bank Draft transaction is subject to a $2.00 processing fee ****One-Time PaymentMonthly RecurringOne-Time Payment*Draft Date:Amount:Monthly Recurring*Draft Date:Amount:Number of Payments:As a courtesy to you, we send billing statements to give you advance notice of each draft amount. Your premium payment amounts are provided in the Finance Agreement. We cannot guarantee that you will receive this notice or that the notice will be received in advance of the Auto Draft. Regardless, payment is still due in accordance with your Finance Agreement.Statement Delivery Preference:*EmailFaxMailFax Number*Email Address* Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code UPLOAD CHECK COPYPlease upload a copy of a voided check to verify your account information. Drop files here or Auto Draft Agreeement* I agree to this auto draft By clicking here you agree to this auto draftSignatureAgreement Auto Draft Authorization I hereby authorize First Solution Financial Services to initiate automatic electronic fund transfer debit deductions from my bank account, identified above, for payment of my insurance policy purchased from the above-referenced insurance policy issued to me by PCIC. This authorization will pertain to all scheduled payments pertaining to my Finance Agreement, including the down payment, and applicable fees and charges. I authorize the financial institution named above to honor such debit, and accept and post entries to my account for any and all installments due under the Finance Agreement. It is further agreed that any additional fees, including but not limited to late fees, non-sufficient funds fees, and cancellation fees, will also be charged and debited from the indicated account should they accrue during the payment term. In the event that a payment made by check, ACH, or draft is returned because of insufficient funds to pay it, the policyholder shall be assessed and agrees to pay an NSF fee of fifteen dollars ($15.00) or the maximum amount permitted by law. If payment is dishonored by the bank designated above from the account specified this agreement may be considered cancelled and the dishonored payment and all remaining payments may be required to be made by check or other negotiable instrument to ensure the continuance of my coverage. I understand that there is no prepayment penalty should I pay off the remaining balance due under this agreement prior to the due dates under the payment term. I understand that this authorization allows First Solution Financial Services to adjust the monthly deductions to reflect any premium changes with the exception of the final premium audit. Any additional premiums and related fees resulting from the final premium audit will be invoiced directly to me. I understand that First Solution Financial Services will notify me if my debit amount changes by more than $1.00 from my previous deduction. Any refunds due on the policy listed above will be refunded by check and not through electronic transfer. I further understand, agree and affirm that: (1) the information I have provided above is correct and accurate; (2) I am authorized to enter into this agreement and am the signer on the above account; (3) funds will be available in the account to cover the amount of the existing obligation on the payment due date(s), and if the payment due date falls on a weekend or holiday, PPAC may debit the account on the next succeeding business day; and (4) this authorization will remain in full force and effect until either (a) I request termination of this agreement by providing PPAC written notice of the desire to terminate automatic debit fifteen (15) days prior to desired termination date, and at least three business days prior to the next scheduled debit date at the address or email below and/or (b) I receive notification from First Solution Financial Services either by email or phone (as provided above) of termination of this agreement resulting from the rejection of an ACH debit due to NSF or a closed account. Authorized and Agreed to by:Signature Date: MM DD YYYY Δ
