Form From M2506.r709 - Automatic Payment Plan
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1
2AMERICAN FIDELITY ASSURANCE COMPANY
Life Division
AUTOMATIC PAYMENT PLAN
Here’s How It Works:
•
To ensure accurate processing, for checking accounts please TAPE a voided, blank
check here. If withdrawal is from a savings account, please TAPE a deposit slip here or
documentation from bank with account information
.
•
IMPORT
Complete and sign the authorization form below.
•
We send your information to our bank and our bank communicates with your bank. Your
premium is paid on the requested withdrawal date. *Any outstanding premiums will be
drafted immediately*
•
***It may take up to three (3) bank business days for withdrawals to reach your account***
•
The payment will appear on your monthly bank statement for your record keeping purposes.
Authorization Agreement for Automatic Premium Payment
Return this form to: American Fidelity Assurance Company
Life Division
P.O. Box 268923
Oklahoma City, OK 73126-8923
FAX 405-523-3841
Name: __________________________________________________________________________________
Address: ________________________________________________________________________________
City: ____________________________________
State: _____________
Zip: ___________________
Policy Number: ______________
Premium
Loan
Annuity Payment Amount: _______________
Policy Number: ______________
Premium
Loan
Annuity Payment Amount: _______________
Policy Number: ______________
Premium
Loan
Annuity Payment Amount: _______________
Policy Number: ______________
Premium
Loan
Annuity Payment Amount: _______________
Policy Number: ______________
Premium
Loan
Annuity Payment Amount: _______________
BE SURE TO INCLUDE ALL POLICY NUMBERS YOU WANT TO DRAFT ON THE DATE SPECIFIED.
Financial Institution:________________________________________________________________________
Address: ________________________________________________________________________________
City: __________________________________________ State: __________________________________
Bank Routing #: ____________________
Bank Account #: ____________________
Checking
Savings
(First 9 numbers on bottom left-hand corner of check.)
(Do not include the check #.)
Requested Withdrawal Date:________________________ Month Effective: __________________________
(Withdrawal Date cannot be more than 15 days after the issue day.)
I hereby authorize you to charge my account for the amount of my insurance premium(s) and/or loan payment(s)
and to make that deduction payable to American Fidelity Assurance Company. In making this authorization, I
agree to all the terms and conditions of this authorization.
Best Form of Contact: Daytime Phone (____)_____-_______and/or E-mail ____________________________
Date: ____________________
Signature: ___________________________________________________
M2506.R709
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