Agency Authorization Agreement Please fax completed form and a

Abram Interstate Insurance Services, Inc.
2211 Plaza Drive, Suite 100, Rocklin, CA 95765
Phone (916) 780-7000 or (800) 955-4465
Fax (916) 780-7181 www.AbramInterstate.com
License # 0D08440
Agency Authorization Agreement
Please fax completed form and a copy of your voided agency trust check to 916.780.7181.
Producer Code:________
Customer Name:
AGENCY INFORMATION:
Agency Name:
Office #
Address:
Contact #
City:
Fax #
State:
Zip:
Email:
BANK INFO:
Financial Institution:
Bank Routing #
Bank Account #
I, the undersigned, hereby authorize Abram Interstate Insurance Services, Inc. to draft from
Producer’s named depository variable amounts indicated by the payment and new business
transmittal received by the Company from the Producer via the producer upload system. Any
disputes regarding the amount drafted from the Producer’s account shall be resolved as soon as
practical. This agreement shall remain in full force and effect until such time as either the
Producer or Company gives written notice of the intent to terminate. Termination of this
agreement does not release any outstanding obligations of the Producer to the Company.
Authorized Signature: ____________________________________
Printed Name:
_____________________________________
Date Signed:
______________________________________
For questions, please call our Accounting Department at 916.780.7000.
Attach Voided Check here before faxing document