Claim Payment Form

Please complete the following form.
() Denotes required field.*
* Name
* Bank Name
* Bank Address
* Bank Routing (ABA) number
* Bank Account Number
* Check if account is	Checking Savings

Contact Information
* Name
* Policyholder Tax ID (Last 4 digits TIN)
Email Address
Fax Number
Phone Number

By signing below, I authorize Great American Insurance Company to directly deposit my MPCI Claim payments into the account designated on this form. This authority will remain in force until I have given written notice that I have terminated it, or Great American Insurance Company has notified me that this deposit service is no longer available.
Accept	Reject