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This form authorizes Special Risks Facilities, Inc. to draft your agency’s bank account for payments due.
Please complete this form and return with a copy of a voided check to: Lee Woodruff, Directors of Agency
Relations - (LWoodruff@specialrisks.com
).
For immediate draft of payment:
Please include the exact amount that you authorize Special Risks to draft from your account today, along with
the insured’s name and/or policy number.
For future payment purposes:
If you are providing your ACH information for future payment purposes, but don’t have a payment to draft
today, please mark the designated box below. We will keep these forms on file for future reference and will
only draft your agency’s account at your written request. **No payments are automatically drafted when there
is a balance due on your agency statement.
Agency Name: ___________________________________________________________________________
Insured Name: ___________________________________________________________________________
Exact Amount Authorized for ACH Draft: _____________________________________________________
Last Four Digits of Bank Account for ACH Draft: ______________________________________________
Please check this box if you don’t have a payment to draft today – information to be kept on file
for future purposes.
(Please continue to page 2 for bank account information)
