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Concord North Carolina 28025
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Coverages
Resources
CLIENT SERVICE
Get a Certificate
MVR Request
ADDITIONAL RESOURCES
YouTube Channel
Schedule a Call
Start Up Checklist
Owner Op Lease Agreement
Accident Release Form
Amazon Relay Intermodal and UIIA Loads
FAQs
TRUCKING LIBRARY
Recent
IRS VCSP – Voluntary Classification Settlement Program
March 13, 2024
How to Get Cheaper Truck Insurance Quotes
November 28, 2023
All Articles
Partners
Contact
About
Our Agency
About Us
Daniel Summers
YouTube Channel
Schedule a Call
Write a Google Review
Get in Touch
9 Union St N, STE 400
Concord North Carolina 28025
704-773-9699
Client Support
Get a Quote Now
First Insurance Funding ACH Form
First Insurance Funding ACH Form
Charles String
2023-05-18T11:08:40-04:00
Company Name
(Required)
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Email
(Required)
Quote or Loan Number
(Required)
Quote/Loan number is found on the Premium Finance Agreement near the top right corner.
Authorized user's name as it appears on the bank account
(Required)
Bank Name
(Required)
Type of Account
(Required)
Checking
Savings
Routing Number
(Required)
Account Number
(Required)
Consent
(Required)
I agree
By signing below, I certify that I am an authorized representative of the Company indicated above and that I have the authority to enter into this Agreement on the Company's behalf. Company understands that this Agreement will remain in effect until it is canceled in writing, and agrees to notify FIRST in writing at least 15 days in advance of any changes in its Designated Account information or termination of this Agreement. Company understands that because these are electronic transactions, it will have limited time to report and dispute errors. In the case of an ACH debit attempt being rejected for Non-Sufficient Funds (NSF), Company understands that FIRST may at its discretion attempt to process the debit again within 30 days, and agrees to an additional NSF charge, as allowed by applicable law, for each subsequent debit attempt that is returned NSF. FIRST reserves the right to cancel this Agreement at any time for any reason, including but not limited to ACH debits being returned NSF, and Company remains liable for timely payments under the terms of the PFA. Company certifies that the Designated Account is enabled for ACH transactions, and agrees to reimburse FIRST for all penalties and fees incurred as a result of Company's bank rejecting ACH debits or credits as a result of the Designated Account not being properly configured for ACH transactions. Company acknowledges that the origination of ACH transactions to its Designated Account must comply with the provisions of U.S. law.
Company authorizes FIRST to initiate recurring ACH debits and credits to the Designated Account to collect all amounts due under the PFA according to the terms of this Agreement.
Signature
(Required)
Upload Signed Finance Agreement
Max. file size: 12 MB.
This will expedite the process
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