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
	Please select an option.

Financial Institution Account Owner/Holder
	Institution Account Owner is required.
Institution Name		Address
	Institution Name is required.		Institution Address is required.
City		State ZIP Code
	Institution City is required.	Institution Zip is required. A valid Institution Zip is required.
Account Type		Account Number
			Where's this? Account Number is required.
Routing Number		Requested Withdrawal Date ?
	Where's this? Routing Number is required.	Withdrawal Date is required.

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) - - Select a valid Policy Symbol Policy Number is required Minimum length of policy is 3 Policy Module can only contain numbers - - Select a valid Policy Symbol Policy Number is required Minimum length of policy is 3 Policy Module can only contain numbers - - Select a valid Policy Symbol Policy Number is required Minimum length of policy is 3 Policy Module can only contain numbers Enter at least one policy number	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) - Policy Number is required Minimum length of policy is 1 This field can only contain numbers Policy Suffix is required - Policy Number is required Minimum length of policy is 1 This field can only contain numbers Policy Suffix is required - Policy Number is required Minimum length of policy is 1 This field can only contain numbers Policy Suffix is required	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) - - Select a valid Policy Symbol Policy Number is required Minimum length of policy is 3 Policy Module can only contain numbers YesNo I wish to contribute to AgriPac $ annually, to AgriPac (annually deduct, in full) AgriPac Contribution Choice Required Contribution Amount Required - - Select a valid Policy Symbol Policy Number is required Minimum length of policy is 3 Policy Module can only contain numbers YesNo I wish to contribute to AgriPac $ annually, to AgriPac (annually deduct, in full) - - Select a valid Policy Symbol Policy Number is required Minimum length of policy is 3 Policy Module can only contain numbers YesNo I wish to contribute to AgriPac $ annually, to AgriPac (annually deduct, in full) Enter at least one policy number	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 - Policy Number is required Minimum length of policy is 1 This field can only contain numbers Policy Suffix is required Withdrawl Amount is required - Policy Number is required Minimum length of policy is 1 This field can only contain numbers Policy Suffix is required Withdrawl Amount is required - Policy Number is required Minimum length of policy is 1 This field can only contain numbers Policy Suffix is required Withdrawl Amount is required Enter at least one policy number

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