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: eftclaims@icbc.com (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
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Application for new EFT Auth
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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
BANK
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
identied above;
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)
