ACH Form

With ACH SERVICE, your premium payments can be automatically deducted from your bank account. This alleviates the cost of postage and checks, as well as the time and effort involved in paying bills.

Once we receive the form below, Marysville Mutual will set your account up for the next billing cycle. You will receive a statement 20 days prior to the due date, showing the amount to be withdrawn from your bank account. You will not receive another statement unless the payment amount changes. Your premium payment will be automatically withdrawn from your bank account within five days after its due date.

No service charge is assessed on ACH payments.

If you have multiple policies you’d like set up on ACH, we only need 1 form, just put all your policy numbers in the block for “Policy Number”.

Financial Institution Name*(Required)

Routing Number(Required)

(9 digit number)

Bank Account Number(Required)

Type of Account(Required)

Checking

Savings

Policy Number (Only 1 form needed for multiple policies-just indicate the numbers on the line)(Required)

Payment Plan(Required)

Monthly

Quarterly

Semi-Annual

Annual

Policyholder Name(Required)

Policyholder Email(Required)

Policyholder Phone Number(Required)

Consent(Required)

I (we) hereby authorize MARYSVILLE MUTUAL INSURANCE COMPANY, to initiate debit entries to my (our) account indicated below and the financial institution named below, hereinafter called FINANCIAL INSTITUTION, to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. This authorization is for the purpose of your insurance policy premium payment. I understand that amounts may vary and authorize payments in amounts as indicated on my billing statement.

Signature(Required)

A LEGIBLE SIGNATURE IS REQUIRED

ACH takes a minimum of 5 days to set up. First payment maybe required.