ACH Recurring Payment Authorization Form

Recurring Payment Setup Options *

Process 20% down payment + 10 monthly payments
Down payment has already been made, only process monthly payments

Name *

First

Last

Email *

Confirm Email

Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Account Type: *

Phone Number Recurring

Preferred Day of Draft *

On what day of the month would you like to pay? Please note: ACH payments can take up to 7 days to process. Please make sure funds are available until the charge posts to your account to avoid a failed payment. Two failed payments and your bank account is blocked from the system.

Name on Account *

Bank Name *

Account Number *

Bank Routing Number *

Bank City/State *

Signature *

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify CPLIC Member Services, LLC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that CPLIC Member Services, LLC may at its discretion attempt to process the charge again within 30 days, and agree to an additional $30 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.

Date *

By completing this form, I authorize CPLIC, RRG to charge my bank account each month on the day indicated below for payment of my policy premium as quoted. Data submitted from this form is securely transmitted and will only be used to connect for payment processes. All information is held confidential and will not be stored past the time needed for processing.

Where can I locate my bank account information?

Image showing the location of routing numbers and account numbers on a check.