Insurance Premium Direct Debit Authorization Form

Managing insurance premium payments shouldn't be complicated. This Insurance Premium Direct Debit Authorization Form makes it simple for insurance providers and policyholders to set up secure, automated payment arrangements that ensure premiums are paid on time, every time.

Whether you're an insurance agency, broker, or in-house administrator, this template helps you collect direct debit authorizations professionally while verifying policy details and capturing essential banking information. The form includes policy number verification, flexible payment date selection, and clear consent for automatic renewals—reducing missed payments and administrative follow-up.

Perfect for insurance professionals who need to:

• Set up recurring premium payments for life, health, auto, home, or commercial policies
• Reduce payment defaults and late fees with automated collections
• Provide policyholders with flexible payment scheduling options
• Maintain clear audit trails for payment authorizations and consent
• Streamline policy renewals with automatic payment arrangements

The form captures policyholder details, verifies existing policy information, collects secure banking details (account name and routing information without storing sensitive data directly), and obtains clear consent for recurring debits. Conditional logic ensures the right information is collected based on payment frequency preferences.

Once submitted, you can connect this form to your policy management system or CRM using Stepper to automatically update customer records, trigger welcome emails, and notify your finance team—keeping your payment processing seamless and your policies active. For policies requiring signed authorization, integrate Papersign to generate and collect legally binding eSignatures on the authorization agreement.

Built on Paperform's secure, SOC 2 Type II compliant platform, this template gives insurance teams a professional, branded experience that builds trust while automating one of the most critical aspects of policy administration.