Page 8 - Application-Sample-Booklet_Texas

PRE-AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER

LOYAL AMERICAN LIFE INSURANCE COMPANY® • PO BOX 559015 • AUSTIN, TX 78755-9015

Proposed Insured’s Name Policy Number (if available)

Financial Institution Name and Telephone Number

Financial Institution Address

9-digit Routing Number Account Number Requested Withdrawal Date (1st - 28th)

Withdraw Payment:  Monthly  Quarterly  Semi-annually  Annually

Type of Account:  Personal Checking Account  Personal Savings Account  Corporate/Business Checking

Name of Employer Group ______________________________________________________________________________________

Purpose for submitting this Authorization (check appropriate box(es)):

 New authorization  Change in checking/savings account

 Change in financial institution  Change in existing coverage

For Checking Account:
Please tape a VOIDED
check in this box.

For Savings Account:
Please attach a letter
from the bank stating the
account and routing number
of your savings account.

APPLICANT INFORMATION FOR FINANCIAL INSTITUTIONS: APPLICANT INFORMATION FOR LOYAL AMERICAN LIFE
As a convenience to me, I hereby request and authorize you INSURANCE COMPANY: It is understood that the drafts will
to pay and charge to my account, drafts drawn on my account be drawn on or about the requested date each month. The
by and payable to Loyal American Life Insurance Company presentation of such drafts to the above Financial Institution shall
provided there are sufficient funds in said account to pay the constitute notice of premiums being due upon the contract and
same on presentation. Such drafts will bear my printed name. association fees (if applicable), and no other notice of premiums
I also authorize Loyal American Life Insurance Company and or association fees (if applicable) due will be given. No premium
any financial institution it uses to initiate credit entries to my or association fee (if applicable) shall be deemed to have been
account or to provide refund of premium or association fees (if paid unless and until actual payment of the draft drawn for
applicable). I authorize you to accept and to credit these entries such premium or association fee (if applicable) payment has
to my account. In the event Loyal American Life Insurance been received by Loyal American Life Insurance Company. The
Company mistakenly deposits funds into my account, I authorize cancelled draft will constitute receipt of premium or association
Loyal American Life Insurance to debit my account for an amount fee (if applicable) payment.The privilege of paying premiums and
not to exceed the original amount of credit. This authorization association fees (if applicable) under this Plan may be revoked by
shall remain in effect until revoked by me in writing, and until Loyal American Life Insurance Company if any draft is not paid
you actually receive such notice. I agree that you shall be fully upon presentation. The payment of premiums and association
protected in honoring any such draft. I agree that your rights in fees (if applicable) under this Plan may be terminated by the
respect to any such draft shall be the same as if it were a check Contract Owner, Financial Institution Depositor if other than
signed personally by me. I further agree that if any such draft is Contract Owner, or by Loyal American Life Insurance Company
dishonored, whether intentionally or inadvertently, you shall be upon 30 days written notice.
under no liability whatsoever even though such dishonor results
in the forfeiture of insurance.

____________________________________________________________________________________________________________

Name of Payor (if other than Insured) Payor’s Address

____________________________________________________________________________________________________________

Print name of Depositor (as it appears on account) Signature of Depositor Date

LY-EFT RETURN TO COMPANY 06/12