Electronic Funds Transfer 


Download the Electronic Funds Transfer Request form and follow the steps to have your premium or loan payment automatically withdrawn from your bank account. Download the form.


Printing and Completing the Form:

  1. Open the form after downloading from above. You will need the free Adobe Acrobat Reader to view and print it.
  2. Fill out the section appropriate to your change.
  3. Print the form and sign it. Then fax it along with a voided check to 608.443.5052. It's that easy!
  4. If you prefer, you may mail the form and the voided check to us at: 123 Town Square Place PMB 749 Jersey City, NJ 07310

Completing the Form Electronically:

  1. Check the boxes you want by moving your mouse over the box and clicking (the cursor will turn from a hand to an arrow). To un-check a box, simply click on it a second time.
  2. To type on a line, click where you want to start and begin typing. You can use the tab key to advance to the next line.
  3. Once you've completed all applicable parts, print the form by clicking on the print button at the top of the screen (part of Acrobat Reader).

Note: When you close the Acrobat Reader, your entries will not be saved. If you print the form and realize you need to add or change something, your entries will still be there as long as you did not close the program.

If you have any questions, please feel free to call us toll free 800.548.2962.

In order to have premium payments withdrawn from your bank account, the policy must be paid current.