ACH Payments & Electronic Funds Transfer Form

Agency Information

Agency Name(Required)

Agency Address(Required)

Street Address Address Line 2 City State Zip

Street Address, City, State and Zip are all required fields.

Agency Code(s) - Can be found on your invoice or statement next to agency name(Required)

Direct Bill Bank Account Information

To be used for direct deposit of direct bill commission.

Type of Account(Required)

Checking

Savings

Select the type of account from the buttons above

Bank Name(Required)

ABA Routing Number(Required)

Must be 9 digits

Account Number(Required)

This field is hidden when viewing the form

ABA Routing Number 4 Digit

This field is hidden when viewing the form

Account Number 4 Digit

Name on Account(Required)

Agency Bill Bank Account Information

To be used for direct deposit of agency bill credit for premium return and/or agency bill commission.

Direct or Agency Bill(Required)

Use same bank account information as Direct Bill

I will supply separate bank account information for Agency Bill

Type of Account(Required)

Checking

Savings

Select the type of account from the buttons above

Bank Name(Required)

ABA Routing Number(Required)

Must be 9 digits

Account Number(Required)

This field is hidden when viewing the form

ABA Routing Number 4 Digit Agency(Required)

This field is hidden when viewing the form

Account Number 4 Digit Agency(Required)

Name on Account(Required)

Contact Info & Verification

Completed by(Required)

Full name of person completing this online form

Contact Number(Required)

Email(Required)

Last 4 of your Federal Tax Identification Number(Required)

This field is hidden when viewing the form

Verification

Thank you for providing banking information to be used for EFT direct deposit from Arlington/Roe. For verification purposes, you will be asked to enter the last 4 digits of your agency’s Federal Tax Identification Number which must match our records. We also reserve the right to contact your agency in the event of discrepancies and/or concerns which may delay processing your request. We appreciate your understanding and cooperation as a partner of Arlington/Roe.

ePay

You are almost done setting up electronic payments to you, our agency partner!

We prefer to receive payments electronically as well. Electronic payments are more secure and efficient for everyone, which is why Electronic Funds Transfer (EFT) has become the standard rather than the exception. Currently, we receive over 70% of payments from our agency partners through our other electronic payment option, ePay.

Though paper check usage has dropped by 82% since 1993, check fraud has escalated and an estimated $24 billion has been lost in the last five years because of it. Using ePay to pay your monthly statement eliminates the risk of check fraud.

After selecting ‘Submit’ below, check out the flyer attached to your confirmation email for more information on how to get started with ePay.

ACH Payments & Electronic Funds Transfer Form

Agency Information

Direct Bill Bank Account Information

Agency Bill Bank Account Information

Contact Info & Verification

Verification

ePay

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