Authorization for Check by Fax/E-Mail
Date: ________________
Name of Insured: ________________________________________
Address: _______________________________________________________
Phone: ______________________________
Permission is granted to Spring Insurance Agency, Inc. to charge my bank account one time only per the
check that accompanies this authorization on the following:
Check: #__________________
Amount: $________________
Signature-Title
Print Your Name
Note: Please remember that the purpose of your faxed check is to provide us with the correct
information to create an accurate check, and for you to retain a permanent accounting record. Also,
please remember that this faxed check contains no other information than would appear on any check
you would have mailed us, and thus it poses no additional risk to security. Please do not mail your
original check. Please retain for your records.
Please fax a voided check along with this authorization form to: 713-864-2068
Or Email a copy of a voided check along with this authorization form to email address:
[email protected]