Form From M2506.r709 - Automatic Payment Plan Page 2

AMERICAN FIDELITY ASSURANCE COMPANY

Life Division

OKLAHOMA CITY, OKLAHOMA

TERMS AND CONDITIONS OF AUTHORIZATION:

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Authorization: Review and complete the Authorization Agreement.

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Payment Amount: The amount deducted from your account will be the balance owed American Fidelity

Assurance Company for your insurance premium(s) and/or loan repayment(s).

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Revocation: This authority is to remain in effect until revoked by either the Policyholder, American Fidelity

Assurance Company or the Financial Institution.

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Stop Payment: You have the right to stop payment of a withdrawal by timely notification to your financial

institution prior to your account being charged. If this occurs, please make other payment arrangements with

American Fidelity Assurance Company.

M2506.R709

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Parent category: Business