Form Ccauth - Authorization Form For John Hancock To Accept Credit Card Payments For Long Term Care Insurance


Authorization Form for John Hancock to Accept Credit Card
Payments for Long Term Care Insurance
Applicant/ Policyholder Name: ______________________________________________
Applicant/ Policyholder Tax ID Number or Social Security Number: ________________
Policy Number (if applicable): ______________________________________________
Type of Credit Card:
Mode of Payment:
Card Holder Name: _____________________________________________
Card Holder Address: ___________________________________________
City: ______________________________ State: _____ Zip: _______
Phone Number: Day ( ) ______________ Evening ( ) _____________
Credit Card Number: ________________________________
Expiration Date: Month ________ Year ______
I authorize John Hancock to deduct from my credit card the advance payment and all recurring required
premiums, based upon my selected method of payment shown on this form. I understand that the
premiums charged will be as shown on the policy or the most recent premium change notice issued to the
policyholder by John Hancock. This authorization is valid indefinitely until such time as I provide written
notice of cancellation to John Hancock at the servicing address stated in the policy, after allowing a
reasonable time to act upon my notification. I agree to contact John Hancock if there are any changes to
my account information. John Hancock reserves the right to terminate this payment plan at any time.
Card Holder Signature: _____________________________ Date: _______
For credit card inquiries please contact Customer Access: 1(800) 377-7311
Please return authorization form to:
New Business policies: Send form with application or with 1064 form for reissues
Inforce policies: LTC Policyholder Services/ X-5
One John Hancock Way, Suite 1700
Boston, MA 02217-1700
Available only for new Custom Care II and Essential Care II policies in states where approved.
Available for Custom Care I and Essential Care I in California and Florida only.
CCAUTH (10/04)


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Parent category: Business