EFT request - Farm Bureau Insurance of Michigan

Please allow 30 days for your Electronic Funds Transfer (EFT) to become effective. Please indicate the FB Account Number you want used for EFT.

Action		FB Account Number
First Name		Last Name

Address

City		State ZIP Code

Phone		Email Address

Agent
	Use this agent. I don't know my agent.

Financial Institution Information

Financial Institution Account Owner/Holder

Institution Name		Address

City		State ZIP Code

Account Type		Account Number
			Where's this?
Routing Number		Requested Withdrawal Date ?
	Where's this?

I authorize Farm Bureau Mutual Insurance Company of Michigan, Farm Bureau General Insurance Company of Michigan, and Farm Bureau Life Insurance Company of Michigan (herein called the "Companies") to deduct insurance premium payments, Michigan Farm Bureau Membership dues, and AgriPac contributions from the account number listed at the named financial institution. If I am not the policy owner/member, I understand and acknowledge paying the insurance premiums/membership dues does not create or otherwise give me any rights to, or under, the Policy/Membership.

I have read, and agree to, the

Are you sure you want to Remove from EFT for this billing account? We will no longer draw from your bank account. We will begin sending billing statements to the billing address indicated.

Yes No

Because your next withdrawal date is within 5 days, we are not able to process your request at this time. We will hold onto your request and process it following your next withdrawal date.

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Property Casualty (P/C) Policies Please note your first withdrawal amount may be higher than subsequent monthly withdrawal amounts. Policy Number(s) - - - - - -	Life & Annuity Policies If requested draw date varies from issue date, one additional month of premium may be required. Term and Whole Life Policies Only Policy Number(s) - - -	Membership Dues I authorize the Companies to annually deduct, in full, the appropriate dollar amount to pay my annual Michigan Farm Bureau Membership dues and AgriPac contribution. Membership Number(s) - - YesNo I wish to contribute to AgriPac $ annually, to AgriPac (annually deduct, in full) - - YesNo I wish to contribute to AgriPac $ annually, to AgriPac (annually deduct, in full) - - YesNo I wish to contribute to AgriPac $ annually, to AgriPac (annually deduct, in full)	Claims Direct Deposit If you would like any eligible claim payments directly deposited into the account specified below, check this box.. Claim Number(s) - Select a claim number symbol Enter a valid claim number - Select a claim number symbol Enter a valid claim number - Select a claim number symbol Enter a valid claim number
	Annuity and Universal Life Policies Only Policy Number(s)Amount to Withdraw - - -

Auto Insurance

Life Insurance

Home Insurance

Farm Insurance

Business Insurance

EFT request - Farm Bureau Insurance of Michigan

EFT Form

Term and Whole Life Policies Only

Annuity and Universal Life Policies Only

Auto Insurance

Life Insurance

Home Insurance

Farm Insurance

Business Insurance

Credits and Discounts

Service Center

Member Savings