Overdraft Coverage Request

  • Complete the secure form below to opt in or opt out of Bank Independent’s Overdraft Coverage for ATM and everyday debit card transactions. Please list all of your Bank Independent checking accounts and specify an opt in or opt out choice for each account. 


    If you have any questions, please contact us at 877-865-5050. We will be pleased to assist you in any way possible. 



    Bold fields are required.

    By accepting standard overdraft coverage for the account(s) below, you are acknowledging that you have read the Overdraft Coverage Form and agree to the terms and conditions of this service.

    First Name:      
    Last Name:      
    Date of Birth:   (mm/dd/yyyy)    


    By choosing YES, you authorize Bank Independent to pay Overdrafts on your ATM and everyday debit card transactions. By choosing NO, you do not authorize Bank Independent to pay overdrafts on your ATM and everyday debit card transactions.
    Account Number:    
               
      
    Account Number:    
              
     
    Account Number:    
              
     
    Account Number: