Changes are processed only if payment for change is on file or received. Please choose payment options to make sure that your request will be processed.

By entering name below, I'm signing ACH form for multiple charges and authorize AGENSTHAUS/INSURHAUS INC to charge the bank account indicated above for any charges related to coverage/policies issued and managed by Agentshaus/INSURHAUS for named insured/client defined above unless alternative payment information is provided upon enrollment. These charges may include, but are not limited to, down payments, recurring monthly payments, endorsement payments, taxes and fees incurred in relation to any insurance coverage written trough AGENTSHAUS/INSURHAUS. This form also applies to any risk or coverage submitted by named insured to cover third party. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify INSURHAUS INC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as coverage is requested. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that INSURHAUS INC may at its discretion attempt to process the charge again within 30 days, and agree to an additional $35.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.

By entering name below, I'm signing form for one time charges and authorize AGENSTHAUS/INSURHAUS INC to charge the bank account / credit card indicated above for any charges related to coverage/policies requested by me filling this form for named insured/client defined above. These charges may include, but are not limited to, down payments, endorsement payments, taxes and fees incurred in relation to change requested. This form also applies to any risk or coverage submitted by named insured to cover third party. I understand that this authorization will remain in effect until all charges for requested change will be applied, and I agree to notify INSURHAUS INC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as coverage is requested. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that INSURHAUS INC may at its discretion attempt to process the charge again within 30 days, and agree to an additional $35.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.

By the signing of this application, I hereby declare that the statements and particulars given on this form are true to the best of my knowledge and belief and that I have not suppressed, withheld or modified any material facts. I agree that should a coverage be changed, this form shall be the basis of the contact, and that any change in pattern or my trade or trade practices shall be advised to the Underwriters who may at their discretion, vary the terms and conditions of this contract. I agree that submitting this form brings obligation to pay for changes requested.

By the signing of this application, I hereby declare that the statements and particulars given on this form are true to the best of my knowledge and belief and that I have not suppressed, withheld or modified any material facts. I agree that should a coverage be changed, this form shall be the basis of the contact, and that any change in pattern or my trade or trade practices shall be advised to the Underwriters who may at their discretion, vary the terms and conditions of this contract. I agree that submitting this form brings obligation to pay for changes requested.