Fillable Agency Authorization Agreement (Abram Interstate Insurance)

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Agency Authorization Agreement (Abram Interstate Insurance)

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Agency Authorization Agreement
Fax to 916-780-7181 or email to aiis@abraminterstate.com
AGENCY INFORMATION:
Trust Account (Premium Sweep) BANK INFO:
Financial Institution:________________________________________________
Bank Routing # ___________________________________________________
Bank Account # ___________________________________________________
Operating Account (Commission) BANK INFO:
Financial Institution:________________________________________________
Bank Routing # ___________________________________________________
Bank Account # ___________________________________________________
I, the undersigned, hereby authorize Abram Interstate Insurance Services, Inc. to deposit to and draft from
Producer’s named depository(s) variable amounts indicated by the payment and new business
transmittal received by Producer from the Company with the quote, as well as the commission amounts
indicated on my commission statements. Any disputes regarding the amount drafted from the Producer’s
account shall be resolved as soon as practical. A $25.00 fee will be charged for all NSF transactions. This
agreement shall remain in full force and effect until such time as either the Producer or Company gives written
notice of the intent to terminate. Termination of this agreement does not release any outstanding obligations
of the Producer to the Company.
Authorized Signature: _______________________________
Printed Name: _____________________________________ Date Signed: ______________________
** ALL PAYMENTS & COMMISSIONS WILL BE WITHDRAWN AND/OR DEPOSITED FROM YOUR
BANK ACCOUNT VIA ELECTRONIC FUNDS TRANSFER **
For questions, please call our Accounting Department at 916.780.7000.
Attach copies of VOIDED Trust and Operating Checks
Agency Name:_____________________________________________ Office# ______________________
Address:__________________________________________________ Contact#_____________________
City:_____________________________________________________ Fax#_________________________
State:________ Zip:___________________Email:____________________________________________
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Agency Authorization Agreement (Abram Interstate Insurance)

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Completed 10 July 2021

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