This authorization permits the Insurance Company (hereinafter "The Company") to withdraw premium payments automatically from your designated bank account. Please complete all fields clearly and sign below.
Policyholder/Insured Name | Policy Number | ||
|---|---|---|---|
A | B | ||
1 | |||
2 | |||
3 |
Contact Phone Number
Email Address
Mailing Address
City
State/Province
Postal/Zip Code
Please attach a voided check or deposit slip to this form to ensure accuracy.
I authorize The Company to initiate debit entries (withdrawals) and, if necessary, credit entries (deposits to correct errors) to the account indicated below. This authority is for the purpose of collecting insurance premium payments.
Financial Institution Name
City/State/Province of Financial Institution
Account Holder Name(s) (must match bank records)
Account Type
Routing Transit Number (RTN) / ABA Number
Account Number
Frequency of Withdrawal
Monthly
Quarterly
Semi-Annually
Annually
Effective Start Date: The withdrawal will begin on the premium due date following The Company's processing of this form.
Amount of Withdrawal
The withdrawal amount will be the standard premium amount due for the selected frequency. I understand this amount may change if the policy is altered, or if a variable/universal life policy requires a change in payment to maintain coverage. The Company will notify me of any changes to the premium amount prior to withdrawal.
I certify that I am an authorized signatory on the bank account specified above.
I understand that this authorization will remain in full force and effect until I provide written notification to The Company of its termination in such time and manner as to afford The Company and the Financial Institution a reasonable opportunity to act on it. Such notification must be sent to The Company’s billing or policy service address.
I agree that The Company shall be fully protected in honoring any such debit or credit, and that The Company shall incur no liability to me or any other party for initiating or failing to initiate a debit or credit, provided such actions are taken in good faith. If any withdrawal is returned unpaid for any reason, The Company reserves the right to charge a fee, re-submit the payment, and/or utilize other billing methods for current and past-due premiums.
Policyholder/Account Holder Signature
Co-Policyholder/Second Account Holder Signature (if applicable)
Date Received
Processed By
Date Processed
To configure an element, select it on the form.