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EFT Authorization

Payment Information:

Billing Address:

Authorization:

By entering the bank account information herein, you hereby confirm that you provide authorization for Skyline Insurance Agency to use the above payment method for payment of the policy being applied for, and that the insurance company is authorized to initiate payments from the bank account that you are hereby submitting for premium payments as they become due. Premiums due include but are not limited to premium, policy fees, inspection fees, installment fees or any applicable fees.

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Timestamp

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February 15, 2024 8:42 am MST

EFT Authorization Uploaded by Matthias Allred - [email protected] IP 50.225.25.74