Unearned Commission EFT |USA | Canada|Stonemark

To make an Unearned Commission EFT 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 checking/savings account, depository name (hereinafter called DEPOSITORY) below ad to debit the said account.

Account Type
CheckingSavings

Bank Name

Bank Routing Number
(Please double check your entry to avoid possible return fees. It MUST be 9 digits.)

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

Verify Bank Account Number

Name on Bank Account

Agency Name

Agent 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 onetime 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