REQUEST TO DEPOSIT FUNDS INTO CHASE ACCOUNT

This form is optional—Complete and include this document with your insurance claim check if you would like any of the claim funds that will be payable solely to you to be deposited into your Chase personal checking or savings account. This form is not required to receive your funds. Any funds that are payable to your contractor will be issued via physical check.

Fill in all required fields below*

The following fields need to be corrected:*

Loan number:

Name(s) of customer(s):

Property address:

Your request is subject to approval.
The following criteria must be met for the funds to be deposited directly into your account:

All payees must be listed on the account you're depositing the funds into.
Payees include all of the parties listed on your mortgage, as well as all of the parties listed on the original insurance claim check (except Chase).
The account must be a Chase personal checking or savings account.

I/We would like the funds deposited into my/our Chase account:

The account number is:

Signature(s) of Customer(s)

Date:

NOTE: All customers' signatures are required.

Once you’ve completed this form, you can scan and upload it to InsuranceClaimCheck.com/Chase, a secure, Chase-approved site. You can also return it to us by mail or fax to:

Regular Mail:

Overnight mail:

Fax:

(Free of charge from

any Chase branch)