EFT eliminates direct bill service fees, check fees and postage! Fill out the information below to start paying your bill by EFT. Or go
to MyHanoverPolicy on hanover.com to enroll and manage your EFT account. It only takes a few minutes and could save you a lot.
BANK ACCOUNT HOLDER NAME AND ADDRESS
First Name: __________________________________ Last Name: _________________________________________ Suffix: _______
OR
Company Name: _________________________________________________________________________________________________
Email Address: ________________________________________________________ Phone #: ________________________________
Address Line 1: __________________________________________________________________________________________________
Address Line 2: __________________________________________________________________________________________________
City, State, ZIP: __________________________________________________________________________________________________
BANK ACCOUNT INFORMATION (Select one)
The information provided will be used by Hanover or Citizens for processing your payment and will be kept confidential.
Bank Name: _____________________________________________________________________________________________________
Personal Account Checking Personal Account Savings Business Account Checking Business Account Savings
ABA/ACH Routing Number: ______________________________________________________
Checking or Savings Account Number: ____________________________________________
Payment Plan*: ____ Full Pay ____ 2 Pay** ____ 4 Pay
____ 10 Pay (for 12 Month Policies only) ____ Monthly
* If no payment plan is indicated, your policy will be defaulted to a Monthly payment plan.
** Available in all states except MA & RI.
Withdrawal Date: (select a day between the 1st and 28th) _________
Write the quote or policy numbers of the policies you wish to enroll in the EFT program in the spaces below:
#1: _____________________________________________________
#2: _____________________________________________________
#3: _____________________________________________________
#4: _____________________________________________________
112-2141A (1/15)
hanover.com
A FEW MINUTES CAN SAVE YOU MONEY!
The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653
Citizens Insurance Company of America | 808 North Highlander Way, Howell, MI 48843
Electronic Funds Transfer Authorization Form
DEDUCTION AUTHORIZATION
By signing below, you are enrolling in The Hanover Insurance Company (“Hanover”) and Citizens Insurance Company of America (“Citizens”) Electronic Funds Transfer payment
plan. Your enrollment will be effective when you receive written notification from your insuring Hanover or Citizens company. You authorize the Hanover or Citizens, as applicable, to
initiate deductions from the bank account identified above to pay the premiums for the indicated policy(ies) and any renewal thereof. Any overpayment or refund may be
deposited into this bank account. This authorization will remain in effect until The Hanover or Citizens and your bank receive timely notice of your termination and a reasonable
opportunity to cancel your enrollment. The information provided will be used by The Hanover or Citizens for the processing of your premium payment and will be kept
confidential. If you fail to provide a date for your EFT payment, you agree for the payment to be made on the 10th of the month in which it’s due. Please note all payments
returned for insufficient funds or account closed will be subject to a fee. If your EFT payment is dishonored by your bank due to lack of funds or for any other reason, we may
terminate your EFT arrangement. Any amount you owe shall not be waived by termination of your EFT agreement. Implementing your EFT request may take up to 30 days.
For new enrollments continue to make scheduled direct bill payments to avoid an interruption in coverage until you receive a withdrawal notice in the mail.
Account holder’s signature _______________________________________________________ Date ___________________________
Mail to: The Hanover Insurance Company, PO Box 15083, Worcester, MA 01653-0083
Email: hanovereft@hanover.com | Fax number: 508-926-5438
If this fax or email has been received in error, please forward it to 508-926-5438
or email it to hanovereft@hanover.com and destroy all copies
(If no date is chosen, the withdrawal will automatically
be made on the 10th of the month.)
SAVE
SAVE
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PRINT
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signature
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