New Account Form

This Agreement governs ACH transactions initiated by Reliable Premium Management to debit or credit the Company indicated below. Both parties agree that this Agreement in conjunction with any of the designated methods constitutes authorization to debit Company’s business bank account, and Company agrees not to dispute any debits with its bank provided the transaction(s) correspond to the terms indicated in this Agreement. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) Company understands that Reliable Premium Management may at its discretion attempt to process the charge again up to 3 times within 30 days, and agrees to an additional $40 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized payment. Company has certified that the business bank account below is enabled for ACH transactions, and agrees to reimburse Reliable Premium Management for all penalties and fees incurred as a result of Company’s bank rejecting ACH debits or credits as a result of the account not being properly configured for ACH transactions.

I authorize Reliable Premium Management to charge the credit card indicated on this form. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; provided the transactions correspond to the terms indicated in this authorization form.