Great Lakes Mutual Policy Services Forms All form fields must be completed except where noted. Incomplete form fields will not allow the form to be submitted to Great Lakes Mutual Insurance. Recurring Payment Authorization Payment Frequency Choose Payment Option Annual Semi-Annual Quarterly Monthly - (no installment fee) Insured/Policy Information Policy Number(s) First Name Last Name Phone Number Email Address Payment Type Checking / Savings Account Credit / Debit Card Billing Address Billing Address Line 2 (optional) Billing City Billing State Billing Zip Code Checking / Savings Account Select Account Type Checking Account Savings Account Name on Account Bank Name Bank Account Number Bank Routing Number Bank City Bank Zip Code Credit / Debit Card Select Account Type VISA MasterCard Discover Cardholder Name Card Account Number Expiration Date CVV (3 digit number on back of card): Authorization BY CHECKING THIS BOX, I AUTHORIZE THE CHARGE ON MY ACCOUNT ACCORDING TO THE TERMS INDICATED IN THIS ACH AUTHORIZATION AGREEMENT. I AGREE TO NOTIFY IN WRITING OF ANY CHANGES TO MY ACCOUNT INFORMATION OR TERMINATION OF THIS AUTHORIZATION AT LEAST 15 DAYS PRIOR TO THE NEXT BILLING DATE. I UNDERSTAND THAT THIS AUTHORIZATION WILL REMAIN IN EFFECT UNTIL I CANCEL IT IN WRITING. I CERTIFY THAT I AM AN AUTHORIZED USER OF THIS ACCOUNT AND WILL NOT DISPUTE TRANSACTIONS WITH MY BANK; SO LONG AS THE TRANSACTIONS CORRESPOND TO THE TERMS INDICATED HEREIN. Verification Code Retype Code
