EFT Authorization Form

EFT Authorization Form

The form below is to submit your EFT enrollment online.


Please complete the information below. All information is required.

Personal Information

 
 
 
 
 
 
 
 

Banking Information

 
 
 
 

 
 

Draw Dates: Your draw date is based on your policy inception date. If your inception date is between the 1st and the 10th, your draw date is the 20th; if between the 11th -24th, your draw date is the 10th (of next month); if between the 25th – 31st, your draw date is the 20th (of next month).

Draw Amounts, Premium Adjustments and Final Audit Premium Payments:
Once enrolled in EFT, your premium payments due will be automatically deducted until you provide Zenith with written notice of cancellation. Premium payment amounts may be adjusted as a result of quarterly self-audits, payroll/class changes, experience modification changes or changes you make to your policy that cause the premium to increase. We will debit your bank account for those charges after providing you with advance notification of the changes. Please note that your final audit premium payments cannot be paid through EFT. These payments will be processed separately and you must pay them through another payment method. Failure to pay your final audit premium payment may result in cancellation of your policy for nonpayment of premium.

EFT Authorization
By choosing the "Accept" button below, I authorize Zenith Insurance Company and its subsidiary (“Zenith”) to enroll me in the Electronic Funds Transfer Option for Premium Payments. I understand that this authorization permits Zenith to electronically debit the account that I have provided for all policy premium payments and, if necessary, credit the account. I understand that payment amounts may be adjusted during the term as a result of quarterly self-audits, payroll/class changes, experience modification changes or changes that I make to the policy that cause the premium to increase. I also understand that EFT is not an available payment option for final audit premium payments. I must pay final audit premium payments separately through another payment method. I understand that this is a recurring authorization and it applies to all future policy renewals, reinstated policies, replacement policies and to all policies I subsequently enroll. I understand this authorization will remain valid until I provide Zenith with written notice of cancellation. I also understand that Zenith and/or my financial institution can cancel my enrollment at any time. I represent that I am the owner and/or authorized signer on the account and I agree to indemnify and hold Zenith harmless from any damage, loss or claims resulting from Zenith’s authorized actions pursuant to this form.

 

If you wish to keep a copy of this EFT Authorization request, please print from your browser prior to clicking Accept.

 
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