ACG378 (022020) Electronic Funds Transfer Authorization and Direction Form Page 1 of 1
Electronic Funds Transfer Authorization and Direction Form
SUBMITTING AN APPLICATION FOR ENROLLMENT OR CHANGE:
You must include completed application and a void cheque or direct deposit form from a bank.
Email: firstname.lastname@example.org (this is a non-replying email address)
Fax: Attention: EFT Claims 604-661-2286
Mail: ICBC, 142 – 151 West Esplanade, North Vancouver, BC V7M 3H9
Application for new EFT Auth
Revision to existing EFT Auth
CUSTOMER’S NAME *
ADDRESS CITY PROVINCE AND COUNTRY
PHONE EMAIL ADDRESS
CLAIM NUMBER ** DRIVER’S LICENCE NUMBER ** POLICY NUMBER** PLATE NUMBER**
* If CUSTOMER is a Corporation, Partnership or Sole Proprietorship, insert full Legal Name.
** One or more ﬁelds must be ﬁlled in to complete the request.
Customer must provide direct deposit form from the bank or a void cheque.
FINANCIAL INSTITUTION NAME AND ADDRESS
NAME ON ACCOUNT BRANCH TRANSIT
NUMBER ACCOUNT NUMBER
By signing this form, the above customer:
1. acknowledges that the Electronic Funds Transfer process may take between 2 to 3 business days;
2. acknowledges having provided to ICBC (a) a void cheque identifying the account number, the nancial institution branch the customer
wishes to have the funds deposited to and the customer’s name, or (b) a nancial institution letter identifying the account number and
nancial institution branch as active and in the customer’s name;
3. acknowledges that the funds (CAD only) will be deposited into the nancial institution account number and branch the customer has
4. represents that the nancial institution account number and branch provided above is a Canadian nancial institution;
5. represents that the above account belongs to the customer; may be individual or joint bank account;
6. acknowledges that if any funds have not been successfully deposited due to reasons such as a closed account, settlement payment of
the above claim will be issued by cheque; and
7. declares, the case of a Corporation, Partnership or Sole Proprietorship, the signatory below is a duly authorized signing ofcer of
the customer and has authority to make this authorization and direction on behalf of customer.
CUSTOMER’S NAME/CUSTOMER BY ITS AUTHORIZED SIGNING OFFICER (Please print) SIGNATURE
TITLE OF AUTHORIZED SIGNING OFFICER, IF APPLICABLE (Please print) DATE (ddmmmyyy)