Print this form by selecting Print from your web browser menu, then:

  1. Complete the printed form.
  2. Attach a Voided Check from your checking or savings account to the printed form.
  3. Return by either:
Mail to: Florida Farm Bureau
PO Box 147030
Gainesville, FL  32614-7030
FAX: 1-352-374-1577
Or: You may drop this completed form at your local County Farm Bureau office.

 

Authorization and Agreement for Recurring Electronic Funds Transfer (EFT) Premium Payments

I have read and agree to the Terms and Conditions for recurring Premium Payments via Electronic Funds Transfer (EFT) as designated below.  By signing this form, I authorize Florida Farm Bureau to initiate through the designated financial entity the appropriate entries to transfer premium payments.  I understand that if I wish to cancel the transfer so authorized below, I must notify Florida Farm Bureau in writing no later than three(3) business days prior to the date of transfer. 
Checking Acct No. ____________________ or Savings Acct. No. ___________________

Name on Bank Acct. _____________________________  Bank Name ___________________

City _____________________________________   State ______   ZIP _______________

Bank (ABA) Routing Number _____________________________________________________
                           (To assure accuracy, please attach a voided check.)

Florida Farm Bureau Account Number ____________________________________________

Signature _______________________________________________  Date _______________

Daytime Phone _______________________ E-mail (optional) _______________________