ACH Debit Authorization

By checking the authorization box, I (the "INSURED"/account holder) request and authorize Heritage Premium Assignment Company, together with its premium finance provider (National Partners PFco, LLC) and their respective affiliates, service providers, and agents (collectively, the "COMPANY"), to initiate debit entries to the bank account I have provided for applicable funds and fees related to my insurance policy and/or premium financing agreement.

Funds will be withdrawn from the bank account I entered, held at the depository financial institution I named (the "DEPOSITORY"). I represent that I am an authorized signer on that account and that the routing and account numbers I provided are accurate.

This authorization applies to the amount(s) shown for my payment plan and to any recurring installment debits required to satisfy that plan. If an incorrect amount is ever debited from my account, I authorize my financial institution to make the appropriate adjustment.

This authorization will remain in full force and effect until the COMPANY has received written notification from me (or my agent) of its termination, given in such time and in such manner as to afford the COMPANY and the DEPOSITORY a reasonable opportunity to act on it. I understand I must give advance notice to allow reasonable time for my instructions to be carried out.

I understand that checking the authorization box has the same effect as my signature on a paper ACH authorization form, that my consent is being recorded with the date, time, and network address from which it was given, and that I may request a copy of this authorization at any time.