Authorization agreement for wire transfer of funds

I (we) hereby authorize Convene Risk Partners, LLC. hereinafter called “company”, to initiate payment credit entries to my (our) checking account indicated below and the depository named below, hereinafter called The Bank, to credit the same to such account.

Depository (Bank)

Bank Name*

Transit/ABA Number*

Bank Address*

Account Number*

Agent Information

This authorization is to remain in full force and effect until the “company” has received written notification from me (us) of its termination in such time and in such manner as to afford Convene Risk Partners and The Bank a reasonable opportunity to act on it.

Agent Number

Agent Name*

Street Address*

Upload Voided Check

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Contact Information

Phone Number*

Fax Number

Attn:

Email Address*

Agency Representative

Note: By signing below, you are choosing to have returns electronically transferred into the account provided. A detailed log report for any monthly returns can be accessed anytime by logging into our website. This monthly report can also be emailed upon request. Please provide the name and e-mail address for the authorized agency representative to receive these statements when requested.

Full Name*

Email*

Signature

By typing your full name below, you agree to our terms and conditions.

Full Name*

Title*

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Questions? Need Help?

You can contact our support team at any time for any questions.

service@convenerisk.com

+1 (888) 676-RISK (7475)