INSTRUCTIONS TO REPRESENTATIVE: Please have the authorized signer complete two (2) copies of this Authorization Form. Please submit one Authorization Form. signed and dated by the authorized signer. to Primerica Life Insurance Company by faxing it to 470-564-5064 or mailing it to 1 Primerica Parkway Duluth, GA 30099-0001. Please provide the other completed original Authorization Form to the authorized signer. IF THE MONEY REQUIREMENT (PREMIUM DUE) SPECIFIED BELOW IS NOT FULFILLED
WITHIN THIRTY (30) DAYS OF ISSUE DATE, THIS POLICY WILL BE CONSIDERED AS NOT TAKEN.
DRAFT DATE: Within one (1) to two (2) business days after receipt of the Authorization Form. ACCOUNT: From the account at the Depository Financial Institution named below ("DEPOSITORY") on record with Primerica Life Insurance Company.
By choosing to pay the premium indicated above for the above-referenced life insurance policy (the "Policy") through an authorized bank draft, I authorize Primerica Life Insurance Company ("Primerica Life") to electronically debit my checking or savings bank account designated above (and, if necessary. electronically credit my account to correct erroneous debits) in the amount indicated above for a one-time bank draft payment ("Payment T.ransfer" By signing below. I hereby indicate my acceptance of the terms of this Payment Transfer and acknowledge and agree to the terms below and on the reverse side of this Authorization Form. I understand that this authorization will remain in full force and effect until I notify Primerica Life of my revocation by submitting a written revocation to Primerica Life Insurance Company Billing Department at PLIC@primerica.com or at 1 Primerica Parkway. Duluth, GA 30099-0001 or by calling our- toll-free Client Services phone line at 1-800-257-4725. Primerica Life must receive notice of revocation from you at least one (1) business day prior to the draft date in order to cancel this authorization.
By signing below. I represent under penalty of perjury that I am an authorized signer and user of the bank account designated above and that I authorize Primerica Life to draft such bank account on the draft date specified above. By signing below. I also acknowledge receipt of a completed copy of this Authorization for One-Time Direct Payment via ACH (ACH Debit / Bank Draft) form.