TO: Payment Processing Section
FAX: 1-800-682-0817
MAIL: Bristol West Insurance Group
PO Box 31029
Independence, OH 44131-0029
SUBJECT: EFT Termination Request Authorization
POLICY NUMBER: _________________________________________
POLICYHOLDER’S NAME: _________________________________________
(Please print)
TELEPHONE NUMBER: _________________________________________
Reason for Termination: _________________________________________
I (policyholder) hereby elect to discontinue installment payments to Bristol West, and its
affiliated companies, in the form of electronic funds transfer (EFT). I understand that Bristol
West must receive this termination notice at least 3 business days prior to the current
installment due date. Otherwise, the payment will be debited from my account via EFT and
this termination will be effective the next scheduled payment due date. In the event that EFT
is terminated for the current installment, I understand that I continue to be obligated to make
the current payment due as outlined on the payment schedule I received when I signed up for
EFT.
Once processing of this termination request is complete, you will receive a letter advising you
that your electronic funds transfer payment method has been terminated. At that time, all
future premium payments to Bristol West must be made in the form of a check, money order
or via WebPay, which is available on bristolwest.com.
___________________________________________ ____________________
<BW.NI1.S> <BW.NI1.DS>
Policyholder’s Signature Date
Instructions:
To insure proper and timely processing, legibly indicate your name and policy number in the
section above and immediately fax to 1-800-682-0817 or mail to Bristol West at the address
shown above.
