Please complete the information below to provide your banking information for Electronic Funds Transfer(s). Please note, additional forms may be needed per carrier requirements, but this allows at least the initial payment to be made. Please work directly with the licensed agent for additional details.

Questions? Contact us at:

531-222-2120

First Name *

Last Name *

Phone *

Financial Institution Name *

Electronic Funds Routing Number *

Electronic Funds Account Number *

Voided Check

Signature *

Clear

I hereby certify that I am the authorized owner of the account provided above and possess the authority to act on its behalf. By submitting this form, I grant consent to Redinbaugh Enterprises, LLC, its subsidiaries, and its representatives to utilize this banking information exclusively for processing payments related to my insurance policies, upon receipt of a written request. I acknowledge that payments will be directed solely to the relevant insurance carrier(s), and understand that an additional carrier-specific form may be necessary.

By checking this box, I also agree to the Privacy Policy terms, per the company's policy.