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 ________________________________________ _________________
Policy Number(s) of Existing Policies:
___________________ ___________________ ___________________
Requested Draft Date, if any (1st-28th) _____________________