Monumental Payment Request printable pdf download

AUTHORIZATION

MONUMATIC PREMIUM PAYMENT PLAN

PAYOR'S AUTHORIZATION TO INSURANCE COMPANY

TO FINANCIAL INSTITUTION

As a convenience to me, I hereby authorize Monumental Life Insurance Company

In consideration of your participating in the MONUMATIC PLAN which Monumental

to draw checks, drafts, or other orders on my bank checking account to make

Life Insurance Company, a Corporation of Cedar Rapids, Iowa, hereinafter called

payments on any policy(ies) listed below.

the Company, has put into effect by which amounts due on policies of insurance

are collected by checks, drafts, or other orders drawn by the Company on the

It is understood that credit for the payment is conditioned upon the order being

accounts of persons who are responsible for these payments, the Company does

honored when presented for payment; that this authorization may be terminated (1)

hereby agree that:

at the option of the company if any check, draft, or other order is not honored when

(1) It will indemnity and hold you harmless from any liability to any person having

presented for payment or (2) upon thirty days written notice by the company, the

an account with you arising out of the payment by you of any check, draft or other

bank, or undersigned to the parties hereto.

order drawn by the Company to its own order on the account of any such person,

or from any liability to any such person, or to any owner or beneficiary of any policy

If this authority is terminated, the amount due on the policy(ies) involved will be

issued by the Company in respect of which such check, draft, or other order is

billed on a direct premium notice basis as provided by the policy provisions unless

drawn, arising out of the dishonor by you, whether with of without cause or

otherwise agreed.

intentionally or inadvertently, of any such check, draft, or other order drawn by the

PAYOR'S AUTHORIZATION TO FINANCIAL INSTITUTION

Company, whether or not such claim or liability asserted against you is based upon

As a convenience to me, I hereby request and authorize you to pay and charge to

the forfeiture, or alleged forfeiture, of a policy(ies) of insurance, the premium(s) on

my account checks, drafts, or other orders drawn on my account by and payable to

which is sought to be collected by the Company by such check, draft, or other

the order of Monumental Life Insurance Company, Baltimore, Maryland, provided

order; and

there are sufficient collected funds in said account to pay the same upon

(2) It will refund to you any amount erroneously paid by you to the Company on

presentation. I agree that your rights in respect to each such order shall be the

any such check, draft, or other order if claim for the amount of such erroneous

same as if it were a check drawn on you and signed personally by me. This

payment is made by you within twelve months from the date of the check, draft, or

authority is to remain in effect until revoked by me in writing, and until you actually

other order on which such erroneous payment was made; and

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

(3) It will defend at its own cost and expense any action which might be brought by

order.

any depositor or any other persons because or by reason of your participation in

the MONUMATIC PLAN.

I further agree that if any such order be dishonored, whether with or without cause

and whether intentionally or inadvertently, you shall be under no liability

MONUMENTAL LIFE INSURANCE COMPANY

whatsoever even though such dishonor results in the forfeiture of insurance.

By:

Authorized in a Resolution adopted by

BANK INFORMATION

the Board of Directors of Monumental

Life Insurance Company on October 16, 1958

PAYOR NAME(S) ___________________________________________________

NAME ____________________________________________________________

___________________________________________________

OFFICE OR BRANCH _______________________________________________

PAYOR SIGNATURE(S) _____________________________________________

STREET ADDRESS _________________________________________________

__________________________________________________

CITY, STATE, ZIP CODE ____________________________________________

ACCOUNT NUMBER

1- Name of Insured(s) __________________________

Policy Number(s) ___________________________________

__________________________________________

____________________________________

__________________________________________

____________________________________

__________________________________________

____________________________________

2- Is this Policy to be added to an existing MONUMATIC account?

Yes

(If yes, the draw date will remain the same for all Policies unless #3 is filled out below)

Existing Policy Number(s):

_________________________________________________ _________________________________________________

3- Draw Date Selection:

(1st thru 28th only)

- CHECKING

- SAVINGS

PLEASE INCLUDE VOID CHECK.

DRAW ALL POLICIES LISTED ON THE ______________ DAY OF EACH MONTH

NOTE-IF NO DRAW DATE IS SELECTED FOR A NEW ACCOUNT, THE DRAW DATE WILL BE THE ISSUE DAY OF THE POLICY

MIL-076 (REV. 6/07) 502

Monumental Administrative Office Copy

Monumental Payment Request

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