Enrollment Form to Receive Commissions

Enroll to Receive Commissions via Electronic Deposit

This form is used to provide payment related information for us to keep on file. It will be used to submit agent commission to your financial institution.

Is this a change to an existing Electronic Payment Account on file?

Agency Information:

Agency Name: *

Address

Address Line 1

City

State

Zip Code

Accounting Contact Person *

Phone

Email *

ARC Number(s)

Checkboxes *

I authorize Centrav.com to deposit agent commission into the bank account listed below. I understand there are no fees for this service, however in the event a deposit is returned due to a closed account, inability to locate account, or invalid account number, I agree to reimburse Centrav all service fees. This authority will remain in effect until I cancel it in writing. *

Financial Institution Information

Bank Name *

Bank Address

Address Line 1

City

State

Zip Code

Bank Routing (ABA) Number

Bank Account Number

Today's Date

A W9 Form must accompany this form to complete registration. If you do not have one, click here to download the form. Once you fill out the form, scan it, and upload below.

Upload your W9 form here

Name

Enroll to Receive Commissions via Electronic Deposit

Agency Information:

Financial Institution Information

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