new business electronic funds transfer (eft) authorization

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PO Box 52121 Phoenix, Arizona 85072-2121 Ph: (888) 724-4267 / Fax: (480) 425-5150

NEW BUSINESS ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION

OWNER AND PAYOR INFORMATION Complete Name of Owner (First, Middle, Last) Complete Name of Payor (If different from Owner)

Policy Number

TYPE OF REQUEST New Business Application (Please include a voided check OR complete the Payor’s Financial Institution section below)

Initial Request for EFT Add to existing EFT under policy number: Existing Policy Changes (Please include a voided check AND complete the Payor’s Financial Institution Section below) Change of bank and/or account number (Allow 15 days for change processing) Change from direct billing to EFT Add to existing EFT under policy number: Please allow a supplementary draft(s) of my account, other than the scheduled draft, to bring my policy(ies) current. WITHDRAWAL DATE AND MODE Initial EFT and any additional EFTs necessary to bring the policy current will be withdrawn based on the Policy Effective Date. Requested withdrawal day of the month for subsequent withdrawals (1st – 28th only): Requested Mode:

Monthly

Quarterly

Semi-Annually

Annually

POLICY(IES) TO BE INCLUDED IN EFT

Insured Name(s)

Policy Number(s)

AUTHORIZATION AND ACCEPTANCE I hereby request and authorize Sagicor Life Insurance Company (“Sagicor”) to make electronic funds transfers from my financial institution as indicated below. This authorization will remain in effect until revoked by me or by Sagicor upon thirty (30) days written notice. I understand that if a fund transfer is not honored by the financial institution, Sagicor will consider the premium unpaid. Any fund transfer returned due to insufficient funds may be re-drafted by Sagicor at its sole discretion. I further agree that if any such fund transfer is not honored, whether with or without cause, Sagicor shall be under no liability whatsoever, even though such dishonor results in the lapse of insurance.

Sagicor reserves the right to revoke this authorization without notice in the event of two (2) consecutive returned fund transfers or a cumulative total of three (3) returned funds transfers in a twelve (12) month period. If this authorization is revoked by Sagicor, it is not eligible to be reinstated for a twelve (12) month period. You must contact Sagicor and request that this authorization be reinstated. Payor/Financial Institution Account Owner Signature Date PAYOR’S FINANCIAL INSTITUTION INFORMATION

Financial Institution Name

Financial Institution Account Number:

Street Address of Financial Institution

Transit/ABA Number:

City

State

ZIP

Financial Institution Telephone Number: ACCOUNT TYPE

Checking (Please include a voided check and/or complete the Payor’s Financial Institution Information section) Saving (Please include a letter from your bank with your routing & account numbers – a deposit slip is not acceptable) NOTE: Debit and Credit Card account numbers are not acceptable

BC100011 EFT

SL550713A