Electronic Funds Transfer Form

To make a Onetime Payment EFT complete the form below. Please allow up to 2 business days for processing your request.

For Faster Processing, please login to your account and submit a payment before our 2:00 PM CST cutoff.
I (we) hereby authorize Stonemark Holdings, Inc., hereinafter called Lender, to initiate debit entries to the checking/savings account, depository name (hereinafter called DEPOSITORY) below and to debit the said account.
Form Completed By:*
- Agent / Broker
- Borrower / Insured
Select Bank Account to Debit:*
- Agent / Broker
- Borrower / Insured
Account Type*
- Checking
- Savings
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.)*
Name on Bank Account*
Borrower / Insured Name*
Phone #*
E-mail Address*
Select one of the following:*
- Account # (begins with 1080)
- Account # (begins with 1070)
- Quote Number
Account #*
Account #*
Account #
Quote Number*
Payment Amount*
I (we) hereby authorize Stonemark Holdings, Inc., 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 of Authorized Signer on bank account*
First Last
Date: 01/22/2022

Onetime Payment EFT Form