Customer Forms

Instructions

Any of the forms available on this page will need to be printed, completed, signed and dated.
Once form completed, the form will need to be faxed to 817-231-4301
or e-mailed as an attachment to and reference the policy# on the e-mail "Subject" line.

Electronic Funds Transfer Authorization (EFT)

The EFT form needs to be completed and signed by the owner of the bank account or credit card account that will be used for Automatic Payment drafts.

Please be advised, accounts that are eligible for EFT are checking accounts and Credit/Debit Cards (AMEX/MC/VISA). Savings accounts are not acceptable and if your checking account is from a Credit Union, you will need to contact the Credit Union to ask if they authorize EFT drafts on their accounts first.

download Download EFT

Policy Cancellation

The Cancellation form needs to be completed, signed and dated by the policy holder.

Please be advised that the date of cancellation will be the same as the date Empower receives the signed cancellation form. All cancellation forms received by empower will be processed as "Insured Request". Therefore, it’s very important you fax or e-mail the form on the day you sign it.

download Download Policy Cancellation

515A Exclusion

The 515A Exclusion form needs to be completed, signed and dated by the policy holder.

The policy holder will need to hand write the name(s) and date of birth of the person(s) that needs to be excluded on the policy.

download Download 515A Exclusion

Statement of No Loss

The Statement of No Loss form needs to be completed, signed and dated by the policy holder. If you are going to submit this form to Empower, you must have prior approval for policy reinstatement by calling Empower Customer Service first.

Please be advised that the past due payment will need to be made on the same day the form is signed and faxed/e-mailed to Empower. The payment will need to be made by phone by calling Empower Customer Service at 1-877-437-5010 phone prompt options press 3 (for customer), then press 1 (auto product) and last press 2 (customer service).

download Download Statement of No Loss