AssurancePay® Recurring Payments

Please review the information below. Click the Submit button when you have verified the information captured is correct. If the information below is not correct, please click on the Modify button to revise. Clicking Cancel will terminate your request and return you to the Account Summary screen.

Your bill account is currently being paid by Recurring Payments drawn from your bank account. From this screen you have options to modify your AssurancePay settings, or cancel your Assurance Pay recurring payments.

Submissions must be at least five (5) business days prior to the next draft date as shown on the Recurring Payment Schedule to alter or stop your next draft.

Acknowledge the statement below and click the Submit button to confirm removing Recurring Payments from your policy. Clicking Cancel will terminate your request and return you to the Account Summary screen.

Policy Number

Policy Holder Name

Name on Bank Account

Bank Name

Bank Routing Number

Bank Account Number

Type of Account

Requested Draft Day

I understand I am responsible for paying any paper billings I may already have received or receive prior to receiving a recurring payment schedule.

Please accept the conditions.

I understand any pending drafts could be from my current bank if not submitted within 30 days of the next draft date.

Please accept the conditions.

AssurancePay® Recurring Payments must be setup at least five (5) business days prior to your next due date.

Note: Any billed installments on your account will need to be paid before automatic drafting will begin.

AssurancePay® Recurring Payments change submissions must be made at least five (5) business days prior to your next draft date as shown on the Recurring Payment Schedule to alter or stop your next draft.

Policy Number

Policy Holder Name

Name on Bank Account

Name on the account is required

Name on the account must be between 4 and 60 characters

Bank Routing Number

Routing number is required

Routing number must be between 4 and 60 characters

Routing number format is invalid

Bank Account Number

Account number is required

Account number must be between 4 and 60 characters

Re-enter Bank Account Number

Account number confirmation is required

Account number confirmation must be between 4 and 60 characters

Account numbers do not match

Type of Account

Checking
Savings

Bank account type is required

Requested Draft Day

Requested draft date is required

Requested draft date format is invalid

If you prefer to use paper instead, please print out and return these documents by mail:

AssurancePay® Enrollment Form

AssurancePay® Change Form

AssurancePay® Opt Out Form

AssurancePay® Recurring Payments

Confirmation

Your request for AssurancePay® has been submitted.

Your banking information change for AssurancePay® has been submitted.

Your Opt Out of AssurancePay® Recurring Payments has been submitted.

If you prefer to use paper instead, please print out and return these documents by mail: