In the event that Socius needs to pay you/your Agency for credits related to insurance policy transactions, the most efficient and secure way to remit funds is through direct ACH transaction. Please complete and sign and date this form to authorize Socius Insurance Services, Inc. to credit the bank account on/after the indicated date below.

Legal Business Name & DBA that authorizes Socius Insurance Services, Inc to credit the bank account indicated below. *

Date *

Billing Information

Address *

Address Line 1

Address Line 2

City

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Zip Code

Bank Details

• Checking
• Saving

Account Name *

Bank Name *

City, State, Zip *

Account Number *

Routing Number *

Contact Information

Name *

First

Last

Title *

Submit