Direct Deposit Authorization Form


Direct Deposit Authorization — Review & E-Sign

Please review your information and authorize direct deposit. If anything is incorrect, use the link below to make changes before signing.

Your Details

  • Name:  

  • Address:  

  • Email:  

Banking Details

  • Bank Name:  

  • Account Type:  

  • Routing Number:  

  • Account Number:  

ACH Direct Deposit Authorization

I authorize RMJ Insurance, LLC and its Direct Partners (the Company) to initiate electronic credit entries to the bank account listed above. This authorization will remain in effect until I submit written notice of cancellation to the company, allowing reasonable time (up to 3 business days) to act on it. I certify that I am an authorized signer on the account and that the information provided is true and complete. I understand deposits may take 1–2 business days to appear depending on my financial institution.

E-Signature Disclosure & Consent

By E-Signing below, I consent to the use of electronic records and signatures for this authorization under the ESIGN Act/UETA. I can request a paper copy at no charge by contacting [email protected] and may withdraw consent at any time, which may delay processing. I confirm that I can access and retain electronic records on this device and that my contact information above is accurate.

Certification

By E-Signing, I confirm that:

  • The account listed is in my name (or I am otherwise authorized to use it).

  • The information shown above is accurate and complete.

  • I will promptly notify the Company of any changes to my bank or contact information.

Leave this empty:

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Signature Certificate
Document name: Direct Deposit Authorization Form
lock iconUnique Document ID: e2849110ecde25cffe83460609c8f8c53dc0a969
Timestamp Audit
August 14, 2025 9:55 am CSTDirect Deposit Authorization Form Uploaded by Roy Matlock - [email protected] IP 23.226.111.238
August 14, 2025 10:05 am CSTRMJ Accounting - [email protected] added by Roy Matlock - [email protected] as a CC'd Recipient Ip: 23.226.111.238
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Audit Trail Serial# d9660cec7181730a06e944e2ab9449ce