Instructions for Direct Deposit of Producer Commission Agreement

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.