BANK DRAFT
AUTHORIZATION
The XYZ Life Insurance Company is authorized to initiate
debit entries to the above account, including the initial premium indicated on
the above check. The Bank is authorized to debit the same to such account. This
authority can be terminated at any time by written notification to the Company,
provided only that the Company and the Bank will have a reasonable opportunity
to act on such notification.
Type of
Account: Checking Savings
X
________________________________________ _________________
Signature Date
Policy Number(s) of Existing
Policies:
___________________
___________________ ___________________
Requested Draft Date, if any (1st-28th) _____________________