Unearned Commission EFT Form

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 Stonemark Holdings, Inc., 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*
- 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*
Agency Name*
Agent Phone #*
E-mail Address*
Borrower / Insured Name*
Policy #*
Select one of the following:*
- My Account # begins with 1080
- My Account # begins with 1070
- My Account # begins with 1071
Account #*
Account #*
Account #*
UEC 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*
First Last
Date: 01/29/2020