1. All of the requested information is required. Complete the below form.
2. If you have any questions relating to this form, please contact Agent Support at:
Phone: 313-877-7400 Option 5; Email: firstname.lastname@example.org
3. Fill in ALL below requested information.
New Agent Information
4. Include a copy of your license with the State of Michigan and submit with this form.
5. Please provide ACH information for commission deposits.
The undersigned hereby authorizes Michigan Basic Property Insurance Association (the Company) to make deposits into my account identified below and authorizes the Bank to accept such deposits. It is agreed that these deposits may be made electronically and under the rules of the Michigan Automated Clearing House Association (MACHA).
This authorization will remain in full force and effect until Michigan Basic Property Insurance Association has received written notification. Only one account is allowed for direct deposit. Please submit a copy of a voided check and a completed W-9 form.