EFT Authorization | Somerset Insurance Solutions

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization form will remain in effect until cancelled.

Account Holder's Name*

First Last

Routing Number*

Account Number*

Bank Name*

Email Confirmation (receipt will be sent to this address)*

Enter Email Confirm Email

By confirming your email address, you authorize Somerset Insurance Solutions, Inc. to setup insurance premium payment(s) with the EFT information provided.