Fillable Electronic Payment Authorization - ExpressIT (MetLife)

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Electronic Payment Authorization - ExpressIT (MetLife)

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The Electronic Payment Authorization - ExpressIT (MetLife) form is 2 pages long and contains:

  • 0 signatures
  • 29 check-boxes
  • 18 other fields

Country of origin: US
File type: PDF

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®
MetLife Auto & Home
Electronic Payment Authorization - ExpressIT
Use this form to allow recurring monthly electronic withdrawals from your bank account.
SECTION 2: Choose what you would like to do
SECTION 3: Policy information
(Select all that apply.)
®
®
SM
(GrandProtect , Combo and PAK II have single account numbers.)
(List policy number(s) you want to include)
(Check policy type for each policy number)
SECTION 1: Policyholder information
First name
Middle initial
Last name
Phone number
Street address
City
State
ZIP Code
(Policyholder & Bank Account Owner name must match)
(Complete one policy option below)
®
Include your home policy in this authorization
Do not include your home policy
(Default, if none selected)
Recreational
Vehicle
Personal Excess
Liability
Home
Boat
Auto
Policy Number(s)
SECTION 4: Electronic payment bank information
(Refer to page 2 for important information)
Bank Name
Bank Routing Number
Bank Account Number
Check the day of the month you would like us to process your payment
1
st
day
8
th
day
15
th
day
Default,
( if none selected)
22
nd
day
SECTION 5: Authorization & signature
Bank Account Owner's Signature
Date
SECTION 6: How to submit this form
Mail:
Fax:
Email:
MetLife Auto & Home
866-743-4890
autoandhomerequest@metlife.com
PO Box 6060
Scranton, PA 18505-6060
(mm/dd/yyyy)
Start a new monthly electronic payment plan
Add a policy to your existing electronic payment plan
Change the bank account for your existing electronic payment plan
OPTION 1:
Package Policies
Account #
OPTION 2: Individual Policies
If you pay your
home
insurance with your mortgage payment
(Choose one)
:
By signing below, I agree that on behalf of all owners of the bank account identified above, I authorize
MetLife Auto & Home to make electronic withdrawals from this bank account,
or any future bank account I
may provide as a replacement, for payment of my premium.
Please complete,
sign and return form
to avoid delays
MetLife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates, Warwick, RI.
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SECTION 7: Additional information
Policy information
Where to find your Bank Routing Number and Bank Account Number
•
•
•
•
•
•
•
IMPORTANT NOTE:
If you are including a home policy in this authorization and you currently pay for your
home insurance as part of your mortgage payment, you must contact your mortgage company to stop that
arrangement to avoid making duplicate payments.
Electronic payment bank information
"Bank" means any financial institution that allows you to write checks.
The name of the policyholder you provide must match the Bank Account Owner, or your bank may not
honor our withdrawal request.
If the date you selected falls on a holiday or non-business day, your bank will determine the actual payment
date.
If your account does not have enough money, your bank may charge you for insufficient funds when we try
to withdraw your payment. We will try to withdraw the money up to three times. If we are unsuccessful, we
will notify you by mail of the missed payment and you may risk cancellation of this payment plan.
If you cancel your policy before the current month's payment date, we will notify you by mail of any balance
due.
We will notify you in advance by mail, if your payment increases by more than $1.
We will notify you either in your policy package or by mail at least 10 days prior to us withdrawing the first
payment from your bank account.
•
•
•
•
Authorization & signature
MetLife Auto & Home is authorized to process payments for all policies indicated on this form and any
future policies I may add.
This authorization will remain in effect for each policy until it is cancelled, however, deductions will stop on
a policy that is cancelled.
As long as my authorization for this payment remains in effect, if a cancelled policy authorized under the
plan is reissued or reinstated, deductions will resume for that policy.
I will provide at least a
25-day
notice, verbally or in writing, to MetLife Auto & Home to change or cancel
this agreement, or I may notify my bank at least three (3) business days before the scheduled date of the
transfer.
We're here to help
Please don't hesitate to contact us if you have any questions.
You can reach us at 1-855-672-3676.
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Electronic Payment Authorization - ExpressIT (MetLife)

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Completed 28 May 2021

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