By completing this secured form, you authorize American Ventures, Inc., D/B/A Advanced Insurance Services to facilitate in providing your checking information as indicated below.
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If you are making a payment for your company, please list the name of your company here.
Name of Authorized Signer
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Bank Routing Number
Checking Account Number
Amout to debit
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To set up auto deductions for an audit payment
To pay an audit in full
To set up EFT payments with insurance company
I authorize uploading payment from my checking to the insurance company
Advanced Insurance Services does not accept payments by check, this information is being accepted as a customer service facilitation only.
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