Pre-Authorized Check Plan Form - American Fidelity Assurance Company

Pre-Authorized Check Plan

Make your life simpler with this convenient payment option…

Pre-Authorized Check Plan

with American Fidelity Assurance Company

Automatic Electronic Funds Transfer

YOU HAVE OPTIONS!

Your payment can be drafted electronically from your bank account saving you the effort of writing and mailing a check each

month. Yearly, that can save you $4.00 in postage and your time.

In addition, you do not have to worry about forgetting to send your payment and possibly lapsing your coverage in the process.

WE MAKE IT SIMPLE FOR YOU!

1. Read and complete each item on the authorization form below.

2. Include a voided unsigned check in order to allow verification of your information.

3. Include any payments due with your current statement.

4. Withdrawals will be around the 1st business day of each month.

AUTHORIZATION FOR PRE-AUTHORIZED CHECK PAYMENTS

2000

Account Number

Pay to the

ABA Transit number

Check

Order of_______________________________________________________ $ _______

_____________________________________________________________ DOLLARS

Number

Bank Name and Address

Memo __________________

______________________

|: 112430088 |: “ 6734 3345 “ 2000

Please complete all information requested and return with your voided, unsigned check to:

American Fidelity Assurance Company - AFES, PO Box 25523, Oklahoma City, OK 73125.

Insured Name(s) _________________________________________

Policy number _________________________

Daytime Phone __________________________________________

Date you want the draft to start __________/ 1 /_______

Month

Year

ABA Transit Number _____________________________________

Account Number _______________________

Financial Institution Name __________________________________________________________________________

Address _________________________________________________________________________________________

City ____________________________________________ State ___________________ Zip ___________________

As a convenience to me, I hereby request and authorize you to pay and charge my account checks drawn on my account by and payable to the order of the American Fidelity

Assurance Company, provided there are sufficient collected funds in said account to pay the same upon presentation. I agree that your rights in respect to each such check shall be

the same as if it were a check drawn on you and signed personally by me. This authority is to remain in effect until revoked by me in writing and until you actually receive such

notice I agree that you shall be fully protected in honoring any such check.

I further agree that if such check be dishonored, whether with or without cause and whether intentionally or inadvertently, you shall be under no liability whatsoever even though

such dishonor results in the forfeiture of insurance.

___________________________________________________

Signature

Date

2000 North Classen Blvd .• Oklahoma City, Oklahoma 73106

M-2210(AFES)