Automatic Withdrawal of Premium Payment Authorization
U.S. Insurance Company of America
3131 Greenhead Dr., Springfield, IL 62711
phone # (217) 391-5252, fax # (217) 391-8742

The person identified below has authorized U.S. Insurance Company of America (USICOA) to debit the bank account electronically through the Automated Clearing House (ACH). USICOA will initiate the debit to the bank account and it will post to the account the next business day.

This form authorizes USICOA, its successors and/or assignees to automatically draft from the checking or savings account one-time for the scheduled amount. The identified personnel authorizes the bank to make payments from the account directly to USICOA. Furthermore, the individual agrees that such withdrawal and payment should be treated as if they personally signed for the withdrawal and payment. If such withdrawal/payment is dishonored, intentionally or inadvertently, USICOA shall be under no liability with respect thereto and the insured will be charged a $50 rejected payment fee.

Email address:
Required to receive confirmation of payment
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Insured's Name
Your answer
Policy or Invoice Number
Your answer
Amount of Payment
Your answer
Authorized Personnel
Name of person making the request
Your answer
Phone #
Contact information in case there are any issues with the withdrawal
Your answer
BANK ACCOUNT INFORMATION:
Please type an apostrophe before typing the routing and account numbers that have leading zeros. EXAMPLE: '001234567
Bank ABA/Routing Number
nine digits (begins with 041..., 071..., 073..., 075..., 081..., 101..., 271..., 283..., or similar )
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Account Number
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Type of account
Check appropriate box
Required
Bank Name
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Name on Bank Account
Your answer
Comments
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