ACH Payment Authorization

Set up direct deposit for your revenue share payments

Carrier Information

Company Legal Name *

MC Number *

EIN / Tax ID *

Business Address

City, State, ZIP

Bank Account Information

Account Type *

CheckingSavings

Bank Name *

Bank Address

Routing Number (ABA) *

Account Number *

Name(s) on Account *

Where to find your numbers:

Check diagram showing routing and account number locations

Verification Document

Upload ONE of the following: voided check (preferred), bank letter, or bank statement (first page).

Click to upload or drag and drop

JPG, PNG, GIF, or PDF (max 10MB)

* Verification document required

Authorization

By signing below, I authorize Guardian Visibility LLC to initiate ACH credit entries (deposits) to the above account. I understand:

• This is for deposits only—Guardian Visibility will not debit this account
• Payments are processed monthly, within 30 days after month end
• I must notify Guardian Visibility 15 business days before account changes
• This authorization remains until I provide written revocation

Your Full Name *

Title *

Phone

Email *

I certify that I am authorized to sign on behalf of the company, the bank account information is accurate, and I agree to the terms of this ACH Authorization. *

Questions? Call us at (406) 430-6100 or email payments@guardianviz.com