Instructions for Direct Deposit of Producer Commission Agreement Form Enrollment Instructions Your agency can enjoy the benefits of receiving your commission quicker by completing the Direct Deposit of Producer Commission Agreement Form. This enrollment form is for your agency’s commission payment and not for your insured’s premium payment. Direct Deposit – ClearSide General will electronically deposit your monthly commissions into your account. Direct deposit will be initiated on the 1st business day of each month. When completing the Direct Deposit of Producer Commission Agreement Form: Verify that the bank account name bank/credit union routing and account numbers are correctly entered. Principal must sign the form. Other persons signing the form must be authorized by which the individual’s name must appear on the bank signature card for the accounts named on the authorization agreement. Signature stamps will not be accepted. Include preprinted voided check. Counter checks or blank deposit slips will not be accepted. If you have multiple locations please be sure to list all the producer codes that will be deposited into the account provided. If you want to deposit the commission for your other locations into separate accounts you will need to complete separate forms. After completing the Direct Deposit of Producer Commission Agreement Form: Fax or mail your completed Direct Deposit of Producer Commission Agreement Form and preprinted voided check directly to ClearSide’s Accounting Department for immediate attention. E-Mail to: [email protected] Fax to: 1-909-243-7560 Or Mail to: Accounting Department ClearSide General PO Box 606 Rancho Cucamonga, CA 91729 If you should need further assistance feel free to contact our Accounting Department between the hours of 8:00 am to 5:00 pm at 888-859-1181. Direct Deposit of Producer Commission Agreement Form Type of Action: Enroll Change Terminate Producer Code (s) ____________________ Agency Name _________________________________ (Include all Producer codes with ClearSide General that will deposit to this account) Address ___________________________City ____________________State _______ Zip ________ Phone ____________________________ Fax#___________________________________________ Email Address __________________________________________ I (we) hereby authorize National General Insurance Company, and its subsidiaries and affiliates (“ClearSide General”), to electronically make deposits and/or withdrawals, and to initiate debit entries in the event of errors to the account named on this form. I (we) hereby authorize the Financial Institution indicated below to accept and post these transactions to my (our) account. Agency’s Financial Institution Name of Checking Account Holder _______________________________________ Bank Name _______________________________________ Bank Address______________________City_____________________State__________Zip______ ABA Routing Number (9 digits) _______________________________________ Checking Account Number _______________________________________ This authorization will remain in effect until I (we) provide written notification to ClearSide General of its termination in such time and in such manner as to afford ClearSide General and the Financial Institution reasonable time to act on it. In the event that my (our) Financial Institution or account number changes, I (we) acknowledge that five (5) business days advanced notice must be given to ClearSide General before the changes takes effect. ___________________________________ ______________________________ (Print Name) (Title) x_________________________________________ _____________________________________ (Signature of Authorized Producer/Bank Account Personnel) (Date) After completing the Direct Deposit of Producer Commission Agreement Form: Fax or mail your completed Direct Deposit of Producer Commission Agreement Form and preprinted voided check directly to ClearSide General – Accounting Department for immediate attention. E-Mail to: [email protected] Fax to: 1-909-243-7560 Or Mail to: Accounting ClearSide General PO Box 606 Rancho Cucamonga, CA 91729 *Please attach a sample check marked as VOID.
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