Monthly Payment Authorization Form To Pre-Authorize Credit Card Charges On The Monthly Payment Option
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1MONTHLY PAYMENT AUTHORIZATION FORM
TO PRE‐AUTHORIZE CREDIT CARD CHARGES ON THE MONTHLY PAYMENT OPTION
1. Policy Number : ________________________________________________________________________________________
2. Named Insured(s):
Insured 1 (Last/First):
_____________________________________________________________
Insured 2 (Last/First):
_____________________________________________________________
(as shown on policy)
Address while in Canada: _____________________________________________________________
_____________________________________________________________
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3. Acknowledgement/Authorization I/We authorize 21
Century Travel Insurance Limited (21
Century) to charge the initial two (2)
months deposit premium, the policy fee, and to make automatic monthly charges to my/our credit card for monthly insurance premiums
due after the activation of my/our coverage in accordance with my Policy Endorsement until a total of 12 monthly payments have been
paid in full, unless my/our coverage is terminated in accordance with my Policy Endorsement. Charges to my/our credit card may be for
variable amounts, as they may change in accordance with changes made to the above policy. I/We waive the right to receive further notice
of the amount and date of each automatic charge to my/our credit card. If the charge is not honoured when any charge is submitted,
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21
Century may attempt to charge that payment again within 30 days. 21
Century reserves the right to ask for an alternative credit
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card if payment is not honoured. I/We or 21
Century may end this agreement at any time by giving written notice. I/We understand that
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cancelling this Pre‐Authorized Credit Card Charge Agreement may result in loss of insurance coverage unless 21
Century receives another
form of payment. I/We understand that failure to maintain adequate emergency medical insurance in force at all times while in Canada
as required of Parent and Grandparent Super Visa holders by Citizenship & Immigration Canada (CIC) would be considered a fraudulent
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activity that 21
Century may be required to report to CIC. Any refund of premium paid pursuant to this authorization shall be made
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to the credit card holder [or policyholder]. I/We authorize 21
Century to disclose personal information in this authorization form to
its financial institution as required for the proper execution of the premium transactions for the policy number specified above.
4. Credit Card Information
Payment Option (Check One R ): £ Visa
£ MasterCard
5. Cardholder’s Name: (exactly as it appears on card) _______________________________________________________________
6. Billing Address: (as shown on credit card statement) ______________________________________________________________
7. Cardholder Contact Info:
Phone: _______________ Cell: _________________ Email: ______________________________
8. Credit Card Number:
Expiry Date:
Security Code
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __
__ __
__ __ __
/
MM /
YY
(3-digit code on back of card)
9. Cardholder’s Signature: _________________________________________________
Date: _______________________
MMM/DD/YYYY
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If you have any questions about our charges to your credit card account, contact us at 1-800-567-0021 or write to us at 21
Century Travel
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Insurance Limited, 1040 Division St., Unit 18, Cobourg, Ontario K9A 5Y5, Canada (o/a 21
Century Travel Insurance Services in British
Columbia).
Fax completed form to 1‐866‐285‐5727 or email to info@21stcenturytravelins.com within 3 business days of the policy
being issued. Failure to do so will result in the entire 365‐day premium becoming immediately due and payable.
MP Auth Form ‐ 1307
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