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

Billing Address

Billing Address Line 2 (optional)

Billing City

Billing State

Billing Zip Code

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