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Insurance Professionals
Financial Institution Cheque Pay/ Pre-authorized Payment (PAP/PAD)
Automatic Payment is a breeze. One time set-up and your payments are made from your chequing account when due as due, so long as funds are available. Should you need to update your information you can do it here.
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First Name, Last Name
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First
Last
Broker Name
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Account Identification
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Please Fill in your Merit Account Number, Merit Tracker Number, or Insurance Policy Number
Bank Name:
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Its a 3 or 4 digit number identifying the bank name, if you don't see it on your cheque, please write bank name
9 digit Transit Number- start with 0, then 3 digit bank number, then 5 digit transit number, e.g. 000399999
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Your Bank Account Number
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It is the number on bottom of your cheque or account number. It can be up to 16 numbers
Amount to be Paid
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Check As May Apply
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One Time Charge
Re-occuring Charge on Payment Due Date
I certify that I am the Borrower or an official representative thereof, that I have the authority to execute this Agreement and to authorize these recurring PAP/PAD Debit payments on the Borrower’s behalf, and that all information regarding the above-referenced Borrower and account holder(s)’ Information is true and correct. I hereby authorize Merit Insurance Premium Financing (hereinafter called “Merit”), to initiate regularly scheduled recurring PAP Debit transactions from the bank account indicated above on the due date or business day after the due date should the due date fall on a non-business day, for any and all installments due under the Merit quote or account number listed above, and if necessary, post credits to the account electronically. The Borrower acknowledges that the amount being debited is subject to change in the event that the Borrower finances an additional premium or a credit endorsement refund is applied to its Merit account. It is agreed that this authorization shall remain in effect until the loan balance is satisfied or until it is canceled by the Borrower through written notice to terminate the authorization. The Borrower agrees to notify Merit in writing of any changes in its bank account information at least 15 days prior to the next scheduled payment due date. In the case of a PAP Transaction being rejected or returned for any reason, Merit may suspend future electronic debits, and may request an alternative form of payment. The Borrower understands that it may be charged fees, as allowed by applicable law, if payment is declined. To guarantee processing, the completed Recurring PAP Authorization Agreement must be received by Merit no more than five (5) calendar days after the current payment due date. Merit will not be liable for any damages, losses, or other liabilities as a result of or in connection with the termination or flat cancellation of your coverage due to any reversed, returned or rejected PAP debit.
Signature by E-name/ Initials
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Secure Upload
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Upload Digital Photo of Front of Your Cheque
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Max file size: 20MB
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Insurance Professionals
