Fillable Recurring Credit Card Authorization Form printable pdf download

Recurring Credit Card Authorization Form

Form to be used for the collection of

Recurring Credit Card information on authorized plans.

Please read this authorization carefully and complete all requested items.

Policy Number: ________________________________________________________________________________________

Name of Proposed Insured: ______________________________________________________________________________

Proposed Policy Owner: ________________________________________________________________________________

E-mail Address: ________________________________________________________________________________________

(Note: A valid e-mail address is necessary in order for us to notify you of your recurring credit card set up, charges, and declines. Without

a valid e-mail address, we will not be able to set up your recurring credit card request at this time. Should you not have an e-mail address

we will need to ask that you select a different method of payment.)

Cardholder Name (exactly as it appears on the card): ______________________________________________________

Cardholder Billing Address:

____________________________________________________________________________

________________________________________________________________________________________________________

Credit Card Number: ____________________________________________ Expiration Date: ______________________

l American Express

l MasterCard

l Visa

Card Type:

Premium Amount: ______________________________________________

Payment frequency of ongoing premium payments:

l Annual

l Semi-annual

l Quarterly

l Monthly

____________________________________________________________________________________________________________

By signing below, I, ______________________________________, authorize American General Life Insurance Company

or The United States Life Insurance Company in the City of New York (the ‘’Company’’) or its representative to charge

my debit/credit card for the amount indicated above on a recurring basis as premiums become due.

I understand and agree that this transaction is subject to the acceptance by, and the terms and conditions of, the

credit card company/bank indicated. I also understand this Authorization is not a part of the policy/contract of

insurance, and that if premiums are not paid within the applicable grace period, the coverage will lapse. I further

understand and agree that the Company shall incur no liability if the bank/credit card company dishonors any amount

charged under this Authorization. I also agree that this Authorization may be terminated at any time and for any

reason by either myself or the Company upon notice to the other party. Upon termination of this Authorization, the

Company will bill me directly for any premium amount due.

I understand that I will be provided with confirmation of the recurring charge amount ; however, the initial charge

to my account will include all currently due and past due premiums.

Signature of Authorized Person on Account:

X ______________________________________________________________________ Date:

________________________

AGLC106248

Recurring Credit Card Authorization Form