Electronic Funds Transfer (Eft) Authorization Form printable pdf download

ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION FORM

For Group Insurance Policies

HARLEYSVILLE LIFE INSURANCE COMPANY

The company above will withdraw the premiums from the specified account. This company will be referred to hereafter as “Company”.

“You”, “your”, “I” and “me” refer to the bank account owner whose name appears below.

How automatic bank draft works: Automatic bank draft is a debit service that offers a convenient way to pay group insurance

premiums.

The company will collect the insurance premiums from your bank account electronically—you do not need to write checks or mail in

any payments. Premium withdrawals will appear on your bank statement, and your statements will be your receipts for payment of your

premium.

Automatic Bank Draft Agreement

I hereby authorize and request the company to initiate electronic or other commercially accepted-type debits against the indicated bank

account in the financial institution named for the payment of monthly premiums and other indicated charges due on the insurance policy,

and to continue to initiate such debits in the event of a renewal, or other change to any such contract(s). I hereby agree to

indemnify and hold the Company harmless from any loss, claim or liability of any kind by reason or dishonor of any debit.

I understand that this authorization will not affect the terms of the policy(s), and that if premiums are not paid within the applicable grace

period, the policy(s) will terminate. I acknowledge that the debit appearing on my bank statement shall constitute my receipt of payment,

but no payment is deemed made until the Company receives actual payment.

I agree that this authorization may be terminated by me or the Company at any time and for any reason by providing written notice of

such termination to the non-terminating party and may be terminated by the Company immediately if any debit is not honored by the

financial institution named for any reason. This must be dated and signed by individual(s) authorized to act upon the bank account

owner(s) as his/her name appears on the bank records for the account provided on this authorization.

Financial Institution Name: _____________________________________________________________________________

Financial Institution Address: ___________________________________________________________________________

City: ___________________________________ State: ________ Zip: _________________

Routing Number:

Account Number:

This agreement authorizes:

A new request

A change in financial institution

Type of Account:

Checking

Savings

Group Name: ______________________________________

Group Policy Number:________________________

Print Bank Account Owner’s Name: _____________________________________________________________________

_____________________________________________________________________

I certify and affirm that I am the Group representative with the authority to authorize Electronic Funds Transfers from this bank account.

Print Name and Title

Print Name: __________________________________________________________________

Signature

Authorized Signature: __________________________________________________________________

Date: ___________________

FORM MUST BE COMPLETED IN FULL, ACCOMPANIED BY A VOIDED CHECK AND RETURNED TO HARLEYSVILLE LIFE

INSURANCE COMPANY AT EITHER THE ADMINISTRATIVE ADDRESS INDICATED ABOVE, VIA E-MAIL TO

, OR FAXED TO 215-256-7683.

Electronic Funds Transfer (Eft) Authorization Form

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